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Pediatricians support drugs for ADHD, but some say therapy should come first

When children are diagnosed with attention deficit hyperactivity disorder, stimulants such as Ritalin or Adderall are usually the first line of treatment.

On Monday, the American Academy of Pediatrics released new recommendations that confirm the central role of drugs with behavioral therapy in the treatment of ADHD.

However, some parents, doctors, and researchers who study children with ADHD say they are disappointed that the new guidelines do not recommend behavioral treatment in the first place for more children, as some recent studies have shown that they can lead to for better results.

When last year, 6-year-old Brody Knapp from Kansas City, Missouri was diagnosed with ADHD, his father, Brett, was skeptical. Brett did not want his son to take pills.

“You hear about the loss of your child’s personality, and they become a shell on their own, and this is not the sparkling little child you love,” says Brett Knapp. “I didn’t want to lose this with Brody because he is a terrific kid.”

Brody's mother, Ashley, had other ideas. She is the principal of the school and herself suffers from ADHD.

“I was in favor of stimulants at the very beginning,” says Ashley Knapp, “simply because I know what they can do to help a neurological disease such as ADHD.”

More and more families face the same dilemma. The prevalence of diagnosed ADHD has risen sharply in the US over the past two decades; 1 out of 10 children now have such a diagnosis.

The updated AAP guidelines recommend that children with ADHD also be screened for other conditions and closely monitored. But treatment recommendations generally do not differ from previous guidelines that were published in 2011.

Any age 6 years or older should start taking medication. as well as AAP says get behavioral therapy as soon as they are diagnosed. Children under 5 years old should start with behavioral treatment before taking any medication.

However, many researchers and doctors who study or specialize in treating children with ADHD are worried that the role of drugs in treatment is too great.

“I think this is a huge bear service, not only for the children we are trying to treat, but also for parents who would rather have behavioral interventions,” says Erica Coles, a psychologist at Florida International University who studies the effectiveness of such actions. treatment.

Behavioral intervention can range from cognitive therapy to school support, which may include special teacher training or placement of children in the classroom. Home changes also help, including such simple ones as helping parents to create a system of expectations, which they reinforce with rewards or soft punishments.

These interventions are designed to teach children strategies that they can use on a daily basis to stay focused, and to strengthen social skills that children who may not develop can concentrate.

After school, Ashley Knapp uses behavioral methods to keep her son Brody in the mainstream; for example, when Brodie curses in despair at some point, his mother forces him to abandon one of his balls.

Ashley says that this should help him learn the discipline and “dirt” needed to complete complex tasks, but it may seem like micro-control to her.

“I don’t like the idea that I should tell my children or anyone else what to do,” Ashley says. “I want them to be able to think for themselves and make the right choice. But at the moment it's just not possible for Brody. ”

However, she says that the training she gives him for his behavior helps.

While the AAP guidelines recommend a combination of drugs and behavioral treatment, studies supporting this combination are considered problematic, according to Coles, as the two approaches were not evaluated separately.

“If you look at studies that have combined treatment with both medication and behavioral interventions, you cannot unravel what leads to the best outcome,” Coles says.

2016 study published in Journal of Clinical Child and Adolescent Psychology We studied the sequence of treatment methods and showed that children with ADHD aged 5 to 12 years who received behavioral treatment before starter pills had fewer behavioral problems than children who started immediately.

A new study co-authored with Coles went even further. It turned out that children with ADHD between the ages of 5 and 13 who first received therapy before taking the medicine often needed less medicine later on.

And 37% of the children who first received the therapy did not need to take pills at all.

“Indeed, this suggests that if we use behavioral intervention as the first line of treatment, we can reduce or eliminate the need for medication in children with ADHD,” Coles says.

Fewer drugs also mean fewer side effects. Some children have trouble sleeping, lose their appetite or even experience personality changes while taking medications, and there is not much research or scientific evidence on what it means to stay on these drugs for many years, especially for those who are still growing.

Meanwhile, studies that support "therapy first" are promising and compelling, but they are small. The Coles study involved 127 children, while a 2016 study conducted by researchers from a number of different institutions in the United States estimated 146.

A spokeswoman for the ADHD Clinical Practice at the American Academy of Pediatrics said the group analyzed a recent “behavior first” study, but found no convincing evidence to warrant a change in guidelines.

However, both the Academy and its critics agree that not enough children are currently receiving adequate behavioral treatment.

“It’s true that when you watch TV, you won’t see many commercials about behavioral treatments, but you can very well see some new ones about medications,” says Carla Allan, a psychologist and ADHD specialist at Children & # 39; s Mercy. in Kansas City, Missouri, and a member of the ADAP Clinical Practice Subcommittee for AAP.

Allan is a therapist with Brody Knapp, and she has been involved in the development of the latest guidelines. Although she wants more patients with ADHD to receive behavioral treatment, she agrees with the AAP decision to adhere to current drug recommendations.

In a 2018 study published in Journal of Pediatrics, only about 60% of children diagnosed with ADHD in the US have ever had Any out-of-school behavioral interventions, while 90% received medication.

Many mental health advocates, including representatives from the National Alliance for Mental Illness, say therapists are not well trained to meet their needs. In addition, interventions can be time consuming for families, and many families cannot afford it.

The Brody family initially avoided medication and relied solely on behavioral therapy to treat ADHD; but after four months of such an approach, Brady suffered an aggressive explosion at home, and, in consultation with the pediatrician, his parents decided to add medicine to his treatment. He is currently taking daily doses of Concerta ADHD.

Brody's dad, Brett, says he's okay with that now. Brett says that, starting with behavioral therapy, before moving on to medication, he gave him insight.

“This is not necessary for the child,” Knapp says of the parental education he received as part of the therapy. “It’s really for parents to understand what a child with ADHD looks like. And for the perspective, I think it really helped, sort of, to understand how I need to interact and how I need to talk and how I need to work with my child. "

This story stems from NPR's partnership with KCUR and Kaiser Health News.

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