Some Current Thoughts on ADHD Treatment for Young Children
(From the Archives, May 2016)
by Chris McGinnis, PhD, BCBA-D
When it comes to ADHD treatment, what is best - medication, play therapy, talk therapy, behavior therapy, sensory therapy, dietary supplements, or some combination?
We've known for some time, in fact, that sugar and dietary changes have minimal to no impact on behavior that satisfies diagnostic criteria for ADHD. Any therapy which relies on the child - particularly young children - remembering to change his ways is ineffective because of the very nature of what ADHD supposedly reflects. Sensory integration based approaches fundamentally lack empirical support. And medication may be effective but it often comes with side effects like appetite suppression, insomnia, and irritability. Appetite suppression leads to the intake of fewer calories which, in turn, at least temporarily suppresses growth.
What works well, what is effective, and what is recommended, depends somewhat on age. The American Academy of Pediatrics (AAP) and the American Academy of Child and Adolescent Psychiatry (AACAP) have recommended behavior therapy - specifically the training of parents in behavioral change strategies - as first-line treatment for children under age 6. That is, children meeting criteria for ADHD should be seen by a competent behavioral health provider for parent consultation and training before medication is prescribed, if at all, for this age group.
Quality therapy before or in place of medication, as a policy, runs counter to common practice in many parts of the country, however. This is likely because of the lack of well-trained helping professionals. There are lots of different types of therapists, including psychologists, mental health clinicians, and clinical social workers. Perhaps psychologists as a group have the most training in science and evidence-based practice out of all types of therapists, yet based on surveys, only around 5% of psychologists consistently offer evidence-based treatment. So even if there are psychologists in your town, it is unfortunately quite unlikely they would offer what the AAP and AACAP recommend.
The Centers for Disease Control and Prevention (CDC), in fact, just published a study by Susanna Visser and colleagues which analyzed whether young children diagnosed with ADHD have been getting best practice. It turns out that between 2008 and 2014, no more than about half of children under 6 with a diagnosis of ADHD across the country received psychological services, whereas about 75% of them received medication, after controlling for how the services were paid for.
This, combined with the fact that "psychological services" were not at all defined in the databases they accessed (that is, some or most of these services likely were not behavioral parent training but instead play therapy or talk therapy) and the knowledge that only about 5% of psychological services (this is not even counting services by nonpsychologists) are evidence-based, in all likelihood the vast majority of young children diagnosed with ADHD have not been getting what they need.
Our clinic has been at the forefront on this and many other issues since our inception. Consistent with the science and best practice, we routinely work primarily with parents, especially with families of younger children, so they may quickly become their children's therapists and therapy occurs every day throughout the day. Every interaction between parent and child can be engineered to be therapeutic. When parents know how to consistently bring out the best in their children, those children begin to practice the right behavior instead of the wrong behavior. Sequential motor practice engages cortical plasticity - the brain adjusts to the practice of good behavior, making what is being practiced more likely to occur tomorrow. Problem behavior, conversely, is practiced less often, making problem behavior less likely to occur tomorrow. But when it does, parents know exactly what to do. We have found lots of success with this approach.
Additionally, our clinic is quite privileged to work closely and collaboratively with the wonderful doctors of a local, high-quality pediatric practice as well as a number of other pediatricians, family practitioners, and neurologists across the region. Children fare best when the family, pediatrician, specialty providers, behavioral healthcare provider, and school are all on the same page and work together.
Competent behavioral health services will also identify and address what I call diagnostic imposters, also known as masquerading conditions, that frequently cause an honest misdiagnosis of ADHD given how utterly unscientific the diagnosis of ADHD is. Such diagnostic imposters include poor sleep health, anxiety, oppositional tendencies, and others. For example, when children get enough sleep they tend to be better behaved, focused, and goal directed as well as calmer and less irritable. In other words, children suddenly getting enough sleep are less likely to satisfy criteria for ADHD.
Medication for ADHD - particularly the psychostimulants - are known to be quite effective for the "combined type" of ADHD - the kind which includes hyperactivity and impulsiveness. It has its place in the treatment of ADHD. However, as reflected in the science and recommendations put forth by leading professional associations like the AAP and AACAP, it may not be needed.
Visser and her colleagues concluded their article thusly: "To effectively mitigate impairments associated with ADHD and minimize risks associated with ADHD medications, it is important to increase the percentage of young children with ADHD who receive evidence-based psychological services, especially parent training in behavior therapy." I could not agree more. If your child has been diagnosed with ADHD, ask your pediatrician for a referral to a behavioral healthcare provider who offers behavioral parent training, or call around to ask various therapists if they help children with ADHD through talk therapy or if they offer evidence-based treatment in the form of giving parents the help they need to help their own children.
Dr. Chris McGinnis is a family psychologist in private practice based in Jupiter, Florida. His website is www.mcginnisbehavioral.com. This article was written when Dr. McGinnis was Clinic Director of the Boys Town South Florida Behavioral Health Clinic based in Palm Beach County, Florida, and collaborating with Palm Beach Pediatrics with collocated services. He continues to offer the very same approach at McGinnis Behavioral in close collaboration with referring physicians.