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New Study: Behavior Therapy Should Come First

New research suggests that children who begin their ADHD treatment with behavior therapy require lower doses of medication and experience greater symptom control than do kids who begin with medication alone.

February 19, 2016

Many physicians and parents consider behavior therapy an alternative treatment option for ADHD, used in conjunction with ADHD medication to help kids learn skills like organization or time management that prescriptions cannot teach. New research shows that behavior therapy works best when it is introduced before medication. Children who were treated with behavior therapy first, and given additional medication if needed, showed faster behavioral improvement than those who began with a stimulant regimen. What’s more, the parents of children who began with behavioral therapy spent an average of $700 less annually on treatment.

The study, published in two papers by the Journal of Clinical Child & Adolescent Psychology, collected data from 146 children with ADHD aged 5-12. Half of the group was given generic Ritalin to treat symptoms. The other half was not treated with medication. Instead, parents attended eight group workshops and one individual lesson to learn behavior-modification techniques. The parents learned to reward good behavior with praise, to withhold privileges and enforce time-outs for misbehavior, and to ignore harmless attention-seeking behaviors. Parents and teachers rated the children’s’ behavior using a daily report card. If kids’ behavior improved, they were given a small treat, like an ice cream cone.

After two months of observation, children who did not show improvement were randomly assigned an additional therapy, either a more intense version of the treatment they were already receiving or a new supplemental treatment (e.g., adding a dose of medication for kids already receiving behavior therapy). Approximately two thirds of kids who began with behavioral therapy received additional treatment, compared to 45 percent of those who started on medication.

The group that received behavioral treatment first broke four fewer rules per hour on average when compared to the medication-first group. The children in the therapy-first group also often required a lower supplemental dose of stimulant medication to curb symptoms than is normally prescribed. This led to annual savings when compared to traditional prescription therapy and behavior monitoring as the same author, Dr. William E. Pelham of Florida International University, describes in a related study.

The researchers hope that these results will prompt larger studies to examine the impact of changing the order of treatment delivery and to further evaluate the emotional and time costs for parents of implementing behavioral techniques.

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