Monday, December 30, 2013

A.D.H.D. Experts Re-evaluate Study’s Zeal for Drugs

NY Times    Twenty years ago, more than a dozen leaders in child psychiatry received $11 million from the National Institute of Mental Health to study an important question facing families with children with attention deficit hyperactivity disorder: Is the best long-term treatment medication, behavioral therapy or both? 

The widely publicized result was not only that medication like Ritalin or Adderall trounced behavioral therapy, but also that combining the two did little beyond what medication could do alone. The finding has become a pillar of pharmaceutical companies’ campaigns to market A.D.H.D. drugs, and is used by insurance companies and school systems to argue against therapies that are usually more expensive than pills. 

But in retrospect, even some authors of the study — widely considered the most influential study ever on A.D.H.D. — worry that the results oversold the benefits of drugs, discouraging important home- and school-focused therapy and ultimately distorting the debate over the most effective (and cost-effective) treatments. 

The study was structured to emphasize the reduction of impulsivity and inattention symptoms, for which medication is designed to deliver quick results, several of the researchers said in recent interviews. Less emphasis was placed on improving children’s longer-term academic and social skills, which behavioral therapy addresses by teaching children, parents and teachers to create less distracting and more organized learning environments. 

Recent papers have also cast doubt on whether medication’s benefits last as long as those from therapy.  [...]

Medication helps a person be receptive to learning new skills and behaviors,” said Ruth Hughes, a psychologist and the chief executive of the advocacy group Children and Adults With Attention-Deficit/Hyperactivity Disorder. “But those skills and behaviors don’t magically appear. They have to be taught.”[...]

A subsequent paper by one of those, Keith Conners, a psychologist and professor emeritus at Duke University, showed that using only one all-inclusive measurement — “treating the child as a whole,” he said — revealed that combination therapy was significantly better than medication alone. Behavioral therapy emerged as a viable alternative to medication as well. But his paper has received little attention. [...]

Most recently, a paper from the study said flatly that using any treatment “does not predict functioning six to eight years later,” leaving the study’s original question — which treatment does the most good long-term? — largely unanswered. 

“My belief based on the science is that symptom reduction is a good thing, but adding skill-building is a better thing,” said Stephen Hinshaw, a psychologist at the University of California, Berkeley, and one of the study researchers. “If you don’t provide skills-based training, you’re doing the kid a disservice. I wish we had had a fairer test.”


  1. There is no question that the person with ADHD, child or adult, must be trained in basic organization skills in order to improve. But trying to train such a person without stimulants on board is doomed to failure. In other words, the drugs allow you to train the person to improve.

  2. We have 9 beautiful children B"H and all but one (the girl) were diagnosed with mood disorder and ADHD and they have been taking either Lithium or Depakot or both and I don't know how I would have been able to function as a working mother without the medicine.  Before the first two boys (twins) were diagnosed it was so difficult to get them to sit with their father or to stop always arguing but since the medicine worked for them we were already aware of the benefits when we had problems with the other children over the years.  Nothing else my husband would tried ever worked and I feel that in the long run it is always better to use medicine than to scream or hit. Really it has been a complete Brocha for all the children and for the whole family.  My husband used to get so frustrated but now B"H they are calm and can learn with him or sit in Shul without a problem.  Not to say that there aren't still behavior problems - they still will sometimes leave the table or run around the playroom but mostly they are well behaved. 

  3. I discussed the issues in the article a while back in
    My conclusions are about half way down , but briefly the reason why SST – social skills training were not effective is the way these skills are taught - top-down in a classroom – so skills are taught in a ' static way ' , also combined with behavior modification which makes kids less pro-social and that SST is taught but not the character traits of generosity and altruism ( difficult to teach altruism when you reinforce behavior with rewards) When SST is taught in a dynamic way by parents and teachers in dynamic settings using collaborative problem solving CPS to promote skills in the context of real problems - the kids pile of problems is reduced and he is learning skills during the process. The RDI – relationship development intervention program teaches skills also in a dynamic way. In addition direct teaching of SST Michelle Gracia Winner's program is helpful


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