Four years ago, the American Academy of Pediatrics introduced new guidelines in the treatment of attention deficit hyperactivity disorder. The guidelines expanded the age range of pediatric diagnosis and treatment, by going up to age 18, and heavily recommended that there be a behavioral therapy component as well as pharmaceutical treatment. In fact, it recommended that preschoolers with ADHD do behavioral therapy first before trying medication.
A new study looked at what doctors were doing in practice. The years studied, 2009-2010, were before the new guidelines, but the study, published in the Journal of Pediatrics, gives some indication of what is happening.
Only 30.7 percent of the kids studied got both behavioral therapy and medication as treatment; 44 percent got some behavioral therapy; 74 percent had received medication; and 12.7 percent received neither. In the 4- to 5-year-olds group, 31.9 percent received behavioral therapy only, 25.4 percent received medication alone, 21.2 percent received both treatments and 21.4 percent received neither treatment.
The Austin-area doctors we talked to were generally in agreement that they take the wait-and-see approach with 4- and 5-year-olds to see if the hyperactivity parents and preschools were seeing was just a matter of maturity and not ADHD. Sometimes they recommend behavioral therapy as well. Only occasionally have they put kids that young on medication. Usually that has been because of the level of symptoms and because there is a parent or sibling with ADHD.
Doctors have to determine if this is just a really active 4-year-old or a kid who has never been expected to behave and needs to learn good behavior practices. They also consider if there is something else happening medically like a problem with metabolism, a learning difference, a neurological disorder, anxiety or a lack of sleep, all of which can mimic ADHD.
For kids ages 6 and older, it’s a bit different. By the time they get to doctors, often something has happened at school or there are repeated behavior problems parents and teachers are seeing. Instead of recommending behavior therapy, they recommend medication first, then behavioral therapy.
“We know that medications work quickly and effectively if appropriate,” says Dr. Julie Alonso-Katzowitz, a child and adolescent psychiatrist at the Seton Mind Institute.
The behavior therapy is also problematic. Texas ranked 50th out of 50 states and Washington, D.C., for children who had ADHD receiving behavioral therapy. It was 46th for children who had both medication and behaviorial therapy.
“There are a lot of barriers,” says Dr. Elizabeth Knapp, a pediatrician with Austin Regional Clinic. Part of this is access to psychological and psychiatric care, especially in rural areas. Another factor is the cost and whether insurance will cover it.
Behavioral therapy also takes work on the part of the parent. For younger children, the therapy is mainly giving parents skills to help kids with coping strategies. As kids get older, the therapy becomes more about the kids learning the skills. To do therapy, parents have to be able to work a class or one-on-one treatment into their daily schedule.
Parents also might not want their child to have the stigma of ADHD, but getting the diagnosis is the first step toward qualifying for getting extra support in school.
Implementation and consistency with behavior therapy also can’t be controlled like a medication. Both parents have to be on board, but it can make a big difference.
“Behavior therapy, if you implement it, it gives your kids and the family something that will benefit them long term,” says Dr. Brad Berg, the medical director of pediatrics for Scott & White Healthcare-Round Rock.