Behavioral Therapy for ADHD: Recommendations Ignored?

Pam Harrison

May 04, 2016

Recommendations from the American Academy of Pediatrics (AAP) that behavioral therapy be used as first-line therapy for very young children with attention-deficit/hyperactivity disorder (ADHD) appear to go largely unheeded, new research suggests.

A new report from the Centers for Disease Control and Prevention (CDC), in Atlanta, Georgia, states that only 55% of young children with the disorder receive some sort of psychological service that may include behavioral therapy.

Regardless of whether they are covered by Medicaid or employer-sponsored insurance, about 75% of children aged 2 to 5 years who are diagnosed with the disorder receive some sort of psychostimulant medication, the report indicates.

"We compared ADHD treatment rates in the years before and after the AAP released guidelines on the treatment of young children with ADHD in 2011," Anne Schuchat, MD, principal deputy director for the CDC, said in a press briefing.

"And we did not find any increase in the use of psychological services after the 2011 AAP guidelines were released, and in fact there was a small decrease in the percentage of children receiving psychological services after the release of the guidelines," she added.

"What these data suggest is that we are missing opportunities for young children with ADHD to receive behavioral therapy, which can be just as effective as medicine but without the risk of side effects."

The report was published online May 3 in Vital Signs.

Worth the Effort

Investigators examined claims data from 5 to 7 million young children who were insured by Medicaid between 2008 and 2011 along with claims data from another million children who were insured through employer-sponsored insurance, the most common form of private insurance.

Examining the latest data from 2014, analyses indicated that for young children with ADHD who were covered under employee-sponsored insurance, 42% received some form of psychological service and that 76% received medication for ADHD.

"This means that less than half of children covered by employer-sponsored insurance in care for ADHD receive any form of psychological service," said Dr Schuchat. "Increasing referral and availability of appropriate behavioral services could help many families with young children who have ADHD."

Georgina Peacock, MD, MPH, director of the CDC's Division of Human Development and Disability, noted that behavioral therapy is a form of treatment in which parents learn specific ways to help improve their child's behavior.

"Children with ADHD have challenging behaviors, and by the time their parents get to me, they are tired and worried about their child," she said during the CDC press briefing.

Behavioral therapy, as recommended by the AAP, strengthens the relationship between the parent and the child, she explained. It also gives parents more effective tools for helping their child learn positive behaviors.

"Behavioral therapy is like having your own personal coach for dealing with challenging behaviors," Dr Peacock noted.

"And a behavioral therapist teaches parents how to provide positive attention and to set and communicate rules."

Parents who use these strategies report that their child does learn to control their behavior better, and this in turn helps the child not only at home but at school and in the child's relationships with others.

"Behavioral therapy takes some work, time, and effort, but the benefits can be lifelong," she added. "It is a proven tool that can make a huge difference for a young child with ADHD."

Potential Treatment Barriers

Commenting on the findings, George DuPaul, PhD, Lehigh University, Bethlehem, Pennsylvania, told Medscape Medical News that one of the challenges in providing behavioral training to parents is that in many areas, there is no trained professional to deliver the therapy. Parents may also lack the resources or insurance coverage to participate in behavioral therapy training, he added.

"There is clear evidence, based on many controlled studies, including those conducted by us at Lehigh University, that behavioral parent training should be the first choice for treating ADHD in young children," Dr DuPaul noted.

"When behavioral parent training is implemented consistently, it can lead to greater parent understanding of behavioral principles, increased use of positive parenting strategies, and enhanced parent-child relationships, and it may delay initiation of stimulant medication as well," he added.

"Hopefully, the mental health community can be responsive to this important call to action."

Vital Signs. Published online May 3, 2016. Full text

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