The drugs that treat attention deficit hyperactivity disorder have become a standard feature of American education. A new study argues behavioral interventions come first.

While the rising rate of attention deficit hyperactivity disorder (ADHD) in children has sparked public debate, most pediatricians and child psychologists stand by their diagnoses.

Many doctors insist the diagnoses are helpful because they give young people access to medications that help them do better in school and lessen behavioral problems.

There is another perspective based on a recent study. The research suggests that children with ADHD diagnoses do better if they get behavioral modification intervention, not medication, as a first line of treatment.

“Ninety percent of kids with ADHD get medication, and typically it’s the only treatment,” lead author of the study, William E. Pelham, Jr., Ph.D., of Florida International University, told Healthline.

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The study divided nearly 150 elementary school students diagnosed with ADHD into two groups.

One group received methylphenidate (Ritalin), which is standard medical practice.

In the second group of students, parents, and teachers implemented an eight-week behavior modification training program. Parents and teachers rewarded continued attention and ignored or punished disruptions.

Within two months, just under half of the students who received medication needed additional help for ADHD-related behaviors. This was true for about two-thirds of the students undergoing behavioral modification.

At first it appeared that receiving medication initially worked better than behavioral modification. However, as the study progressed, the findings uncovered something different.

Half of the students in the first group who still showed symptoms of ADHD got a higher dose of Ritalin. The other half of that group had behavioral modification added to their existing dose of medication.

Half of the students in the behavioral modification program who still showed symptoms of ADHD continued their behavioral regimens and also got a standard dose of Ritalin. The other half of this group participated in a more intensive behavioral modification program and did not receive medication.

At the end of a year, the students who had behavioral training before they were given Ritalin were doing better than any of their peers. Behavior modification was also more effective among children who received only one type of treatment.

In fact, a quarter of the students in the behavior modification group who were prescribed Ritalin two months into the study didn’t need medication by the end of the study.

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Why does the order of treatment matter?

The American Academy of Pediatrics (AAP) recommends a mix of behavioral modification and medication, but doesn’t detail how the two treatments should be combined.

“Our study will help clarify what the AAP recommendations are,” Dr. Pelham said.

The study implies that medication has become the standard of care for children with ADHD. Parents, teachers, and pediatricians usually focus on how quickly something works instead of how well it works, according to Dr. Francisco Castellanos, a professor of child and adolescent psychiatry at New York University.

“What Pelham has found is that when parents invest in incorporating standard behavioral principles into their lives, then the additional effects of medication result in a better outcome. I think that makes a lot of sense and it matches my experience when I was working as a clinician,” Dr. Castellanos told Healthline.

In a second study, Dr. Pelham documents that using the behavioral modification approach first, and medication as a backup, is more economical than medicating children when they are first diagnosed. This is true even when factoring in the time parents are required to participate in behavioral modification.

Even with Dr. Pelham’s findings, it may be some time before doctors move away from providing medication immediately following an ADHD diagnosis.

“Pediatricians are too busy, too poorly reimbursed, and rarely have access to behavioral specialists who are sufficiently versed in these treatments,” Dr. Castellanos said.

In the future, more insurers may cover behavioral modification training programs if additional evidence supports this treatment option is effective and less expensive than drugs.

“Most insurance companies pay for medication but don’t pay for parent training,” Dr. Pelham said. “They haven’t done it because their perception is it costs too much. Overall, starting with behavior is not only better, but it’s also cheaper.”

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