Why the Key to Treating ADHD Goes Beyond Medication

Most kids who've been diagnosed with attention-deficit disorder aren't getting the right mix of medication and behavioral management that can make all the difference.

Game Changer ADHD Child in Middle of Atomic Whirl Illustration
Photo: James Yang

About 6.4 million American children have been diagnosed with ADHD, a neurodevelopmental condition that causes problems with attention span, hyperactivity, and impulsivity, according to the Centers for Disease Control and Prevention (CDC). That’s 1 in 10 school-age children (14 percent of boys and 6 percent of girls)—so if your child is among them, there are more moms in your shoes than you might realize.

Because the rate of ADHD has increased by an average of 3 percent every year for the last decade, some experts and parents have speculated that the condition is overdiagnosed, with doctors quick to medicate any fidgety kid. “But despite the rise in cases, ADHD is still undertreated,” says psychologist Mark Stein, Ph.D., director of the ADHD and Related Disorders Program at Seattle Children’s Hospital. What he means: While more children are being diagnosed, most are offered a prescription drug and nothing else. Most often it’s a psychostimulant medication like Ritalin, Adderall, or Concerta. Seventy percent of kids between ages 4 and 17 who have been diagnosed with ADHD now take one of these drugs, and 43 percent manage their condition with medication alone, according to 2015 research from the CDC.

“However, medication alone doesn’t teach skills or prepare children and their families for the difficulties they will face at home, at school, and socially,” says Dr. Stein. Untreated or undertreated ADHD can have devastating consequences: Kids in elementary school who commit suicide are almost twice as likely to suffer from ADHD as from depression, according to a recent study in Pediatrics. And ADHD isn’t something most kids outgrow, although the nature of the disorder changes with age. If your child struggles to sit still at circle time in preschool, he may go on to have trouble focusing enough to safely drive as a teenager and manage his finances as an adult. That’s why experts now say that including behavior-management therapy is the key to making sure that your child has lasting improvement throughout his life.

The Promise of a Pill

Psychostimulants work by increasing the brain’s level of dopamine, a neurotransmitter that communicates pleasure and enhances motivation. Studies suggest that having a low level of dopamine prevents a child with ADHD from feeling satisfied by completing a task that requires focus. When psychiatrists first began diagnosing and treating ADHD in the 1980s, it was rare to hear a parent ask to put her kid on drugs. “Back then, you had to convince families to try medication after everything else had failed,” recalls Steven Cuffe, M.D., chair of the psychiatry department at the University of Florida College of Medicine-Jacksonville.

The real turning point came in 1999 when the initial results of a large study funded by the National Institute of Mental Health (NIMH) showed that psychostimulants were more effective than behavior therapy by the end of a 14-month treatment period. The side effects of medication include appetite suppression, weight loss, headaches, tics, and sleep problems.

“These days, children usually come to a psychiatrist having already tried medication. It’s been a total paradigm shift,” says Dr. Cuffe. Some of that change can be chalked up to a more widespread understanding of the condition: Since we’ve all heard of ADHD, you’re more likely to mention your kid’s epic tantrums or short attention span to your pediatrician, And she’ll probably reach for her prescription pad. In fact, pediatricians now prescribe about three-quarters of ADHD medication. “Although they shouldn’t just write a quick prescription, it’s hard to do more when they only see a child for a few minutes at a well visit,” says psychologist William Pelham, Ph.D., director of the Center for Children and Families at Florida International University, in Miami. “Medication changes a child’s behavior within 30 minutes of taking the pill,” explains Dr. Pelham. But when the dose wears off four to 12 hours later, the behavior goes right back to the way it was before. Says Dr. Pelham, “The only way to maintain the good behavior you get on the drug is to never stop taking it.”

Nicole Gonzalez knows all this firsthand. By the end of kindergarten, her daughter Daniella was spending up to seven hours a day in time-out because her teachers didn’t know how else to handle her outbursts. “We got calls every week saying, ‘Your daughter can’t sit down, she won’t focus, she’s disruptive,’ ” recalls Gonzalez, of Miami. At home, every family dinner ended in spilled milk and tears. On one trip to the grocery store, Daniella deliberately dropped and broke a glass jar of spaghetti sauce. “We were screaming at each other in the pasta aisle,” Gonzalez says. “I thought they might take me to jail.”

Gonzalez’s mother saw a billboard advertising Dr. Pelham’s program, and he diagnosed Daniella with ADHD. The family decided to enroll her in the center’s summer behavior-treatment program, a day camp specially designed for kids with ADHD. It involves an intensive behavior-management program and a weekly parent training program. Within the camp, Daniella was enrolled in a study to explore how stimulant medication works in combination with behavior-management therapy. She was randomly assigned to a group receiving no medication for the first part of camp and a low dose of medication for the second part.

During the first three weeks, she made progress but clearly needed more than behavioral intervention. However, within hours of swallowing her first pill, the change in Daniella’s behavior was apparent: “We went from 38 time-outs in one day to zero the next,” Gonzalez says. And instead of storming out of camp in tears, Daniella skipped to her mother’s car, flushed with pride at her success at mastering the behavioral challenges she’d been working on. But when school started again, Dr. Pelham’s team recommended that Daniella take a break from the medication on weekends because her mom was worried about her small daughter’s birdlike appetite. And Gonzalez says the change when Daniella goes off the medication is pretty instantaneous too. On the days she takes her Concerta, Daniella can focus on getting ready for school in the morning, run errands with her mom, and sit still at the dinner table. “On the weekends, she reverts to her old self,” Gonzalez notes. “I compare ADHD medication to glasses,” says Thomas E. Brown, Ph.D., a clinical psychologist with Understood, a nonprofit advocacy and educational organization for the parents of kids with learning and attention challenges. You can see well when you wear glasses, but your vision gets blurry again as soon as you take them off.

The Power of Therapy

Even though parents appreciate how helpful medication is, the take-home message is clear. “When you have a special child, you need to learn special powers,” says Gonzalez. That’s why a good behavior-management program focuses as much—if not more—on training parents how to manage ADHD behavior as it does on teaching coping strategies to kids. Gonzalez participated in the program for parents of the kids whom Dr. Pelham treats. Such programs typically involve eight to 12 weekly one-hour sessions, during which families are trained on how to set clear expectations and offer praise and rewards (like screen time) when a child’s behavior is on track, as well as how to use consequences (like time-outs) more thoughtfully when she acts out. The approach is used with kids as young as preschoolers, and as they get older the focus shifts to helping them develop their own problem-solving skills so they won’t always rely on getting rewards.

Research shows just how effective behavior management is: In a major study that Dr. Pelham’s group published last year, after eight weeks of group parent-training sessions like the ones Gonzalez attended, 35 percent of children were able to manage their ADHD without medication. For the children who ended up needing a combination of behavior therapy and medication, those like Daniella who started out with a few weeks of behavior therapy before adding medication did far better than those who tried drugs first; they were also able to take much lower doses of medication.

Both parents and teachers need to be on the same page. Many programs will send a therapist to do training sessions with key personnel at a child’s school, as was done with Daniella. However, the Individuals with Disabilities Education Act requires that schools implement a “504 plan” (named for the section of the federal law) to provide accommodations for a child with ADHD. If your child hasn’t been officially diagnosed, you’ll have to ask your pediatrician for a referral to a child psychologist or a developmental pediatrician, and insurance coverage varies. You can also check local teaching hospitals and universities with graduate psychology programs to see whether they offer free evaluations and even free or low-cost therapy as part of their research and student-training efforts. Visit understood.org for more information about ADHD-treatment resources.

There’s no getting around the fact that this is a lot of work for everyone involved. “It’s easy for me to stand up in front of a group of parents and work them through a lesson,” acknowledges Dr. Pelham. “The hard part is for them to go home and actually do it. That’s much harder than just giving your kid a pill in the morning, but it’s the only thing that works in the long run.” After Amanda Morin's son, Benjamin, bolted out of the car in a crowded parking lot, he began receiving a type of behavior-management therapy called Solution-Focused Brief Therapy at school, to complement the low dose of Concerta he was already taking. At the same time, Morin and her husband worked to implement more consistent expectations at home, with clear daily routines, visual schedules, and checklists. “There are days when we totally forget to follow through on something, because that’s life,” says the mom from Portland, Maine. But overall, she says the combination of medication and behavior management has been game-changing for Benjamin and the whole family.

Daniella, now 8, still needs medication, but the real advance has come from behavior training. “Daniella isn’t tugging at my shirt while I’m trying to cook dinner now, because she knows she gets me all to herself during our daily five minutes of 'special time,'" Gonzalez notes. “We can go to the store because I set expectations like ‘no throwing’ beforehand, and she knows if she does well she’ll get a reward.” When tantrums happen, Gonzalez and her husband have learned to squat down to Daniella’s level, make eye contact when they talk, and to really listen.

There’s been an even more profound shift in Gonzalez’s ability to enjoy and appreciate her daughter’s strengths. “Daniella is the first to give a compliment, she observes everything, and she’s an animal whisperer; she knows how to make her pet lizard fall asleep in her hand,” Gonzalez says. “I used to think, ‘Why can’t you be like a normal kid?’ Now I know she just shines in a different light.”

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