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Mar
06

In a recent commentary in The Boston Globe, pediatrician Claudia Meininger Gold wrote, “medication can’t fix a broken childhood.”  She goes on to say, “with our over-reliance on psychoactive medication, we have created another Ponzi scheme where, just as Bernard Madoff’s investment fund was not really earning any money, we are fooling ourselves into thinking that we are helping these children in any significant way.”

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In fact, a recent US News & World Report also provides in-depth coverage of this topic, starting first by citing the recent recommendation of the National Institute for Health and Clinical Excellence of the UK.  They recommend the trial of behavioral intervention prior to medication for the treatment of children diagnosed with ADHD.

This is similar to recommendations of US professional organizations, including the American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry.  Both recommend a trial of behavioral interventions as the initial treatment for children with mild to moderate symptoms.  They also recommend the initiation of the intervention when children have a poor response to stimulant medication before initiating treatment with other drug classes.  These recommendations are based on controlled research investigating the relative effectiveness of various methods of treatment.

Recently, the Hastings Center also published a report in Child and Adolescent Psychiatry and Mental Health, which states “the facts surrounding the most effective treatments of ADHD are complicated and incomplete.” They cite an influential, federally-funded study comparing stimulant medication with behavioral therapy and combination treatment — which was widely interpreted as finding medication superior in reducing ADHD symptoms, even though a follow-up study found “all three treatment options to be similarly effective.”

With all of the research and guidelines supporting the use of behavioral interventions as essential in the treatment of ADHD, it is disheartening to find that few children and parents have access to these services.  Busy primary care physicians lack the time to train parents and counsel children.  Insurance carriers often make it difficult to obtain the services of a mental health professional with the expertise to provide these evidence-based services to ADHD children.  Even when available, parents often do not have the time to keep the necessary appointments.  Thus, for many reasons, this highly effective intervention is highly underutilized.

In answer to this problem, I developed the Total Focus Program to provide a comprehensive package of behavioral interventions to use in the home. It’s geared not only towards parents, but to children with ADHD as well.  It provides six interventions recommended by the National Institute of Mental Health: parent training, behavior modification, cognitive behavioral therapy, social skills training, relaxation training and cognitive rehabilitation “brain training” exercises.  It has also been reviewed and endorsed by several leaders in the ADHD field and is the key component in an outpatient program for ADHD children provided by the Department of Psychiatry at UC Irvine School of Medicine.

Perhaps most importantly, as the parent of a son with ADHD, I made sure that when I created Total Focus, I wrote it in a way that would bring the whole family together to work as a team. I wanted parents to be able to help their kids feel good about themselves while giving them a sense of being able to positively influence their child’s psychological development.


     

If you find any comments that are rude or inappropriate, please contact us immediately.

  • dlmiller1054 Says:

    It is my opinion that in some cases, drugs are being perscribed when they should not be prescribed. In some kids I think it is just a phase they are going through. I do not believe drugs are good for our bodies. Less is more. However, in other cases it is for real. These are the cases that our hearts go out to. It takes a lot of love and understanding to work with these kids.

  • Laura Says:

    We are in this very situation. My 11 year old daughter tried Concerta for about 6 months, 2 years ago. The only thing it did for her then was keep her in her seat. Her grades did not improve. When we increased her dose, she did not like the way it made her feel, so we quit. We went for counseling sessions for a year but because we our insurance did not cover it, we had to stop because we were having trouble paying our bills with the additional cost of counseling. I think we need to try the Total Focus program. Our family is very stressed right now and we need to do something.

  • Annita Woz Says:

    How good to see your blog on this topic! AND that you have a son who has benefited from alternative interventions. Why are we seeing so much of these behavioral labels and why is medication the first option rather than the last!? I am also concerned that teachers/schools do not have time/make time for training on this kind of learning style. ADHD issues seem to be so damaging to the learning curve and emotional health of kids as they try to manage it in school I have been thinking about this alot since hearing about a book called The Diseasing of America’s Children, 2008, by Thomas Nelson Publishers, John Rosemond and pediatrician Dr. Bose Ravenel. I hope that opinions like Rosemond’s and yours will be heard and explored. How can I support the spread of this information? Should I call my school district? Call my state representatives? What processes are there in our social servcies system to provide this kind of training for parents/teachers?

  • sanchit Says:

    My son has been on Concerta for 8 years, he is 13 now and I plan to use the Total Focus techniques to help wean him off his medication. Mostly becasue I am concerned about his adolescent growth. The medication is very effective for him..he is a good student and stays out of trouble. But, I am concerned that this may not continue once he is off his medication. We had a very difficult time when he was 5 and I fear if we go thru similar issues as he enters puberty it may be “all hell breaking loose”

  • For The Children Says:

    I am a school social worker, as well as a clinical social worker. As your article states, behavioral intervention is oftentimes sufficient to support children with mild to moderate symptoms of ADHD. However, for children who have difficulties in multiple areas of executive function ie. active working memory, recall on demand, emotional dysregulation, focus, sustaining effort, impulsivity, behavioral intervention oftentimes is not sufficient. ADHD is a disorder that involves brain chemistry and it has been my experience that too often children who could benefit from medication are denied treatment because of the insistence that behavioral intervention should be sufficient. Ultimately, their self-concept begins to erode because they can’t seem to do what they know they should be doing…The adults in their world are trying to help them, they are trying to do what they are supposed to do, and doing the best they can, and they still can’t succeed. They begin to feel that they are ‘stupid’ or that it really must be true that they are ‘lazy’ because if it weren’t true, they ask themselves, “Why am I not changing then?” It is disheartening to watch as this scenario unfolds. We know that for the majority of children who are moderately to significantly impacted by symptoms of ADHD and behavioral interventions did not prove to be effective for them, as they grow into adulthood, it is a given that the quality of their lives will be negatively impacted. The only question is, to what degree.

    If tight, consistent behavioral intervention is not proving to be constructive and beneficial, it is time to explore medication. The American Academcy of Pediatrics protocol for medication? If one medication does not effectively reduce the symptoms of ADHD, after having been titrated appropriately, then initiate different medication. With the various delivery systems, and the myriad of choices in types of medication, it is important to emphasize that determining a medication is not a one-size-fits-all treatment–every child is different.

    In regard to the “influential, federally-funded study comparing stimulant medication with behavioral therapy and combination treatment” that was referenced, the National Institute of Mental Health study, your statements were misleading. As published in the August, 20007 Journal of the American Academy of Child and Adolescent Psychiatry (JAACAP), Dr. Peter Jensen of Columbia University states, “Our results suggest that medication can make a long-term difference for some children if it’s continued with optimal intensity, and not started or added too late in a child’s clinical course.” Results of the follow-up study can be found on the National Institute of Mental Health website under the article title, “Improvement Following ADHD Treatment Sustained in Most Children”.

    As the American Academy of Pediatrics states in its Clinical Practice Guideline: “Treatment of the School-Aged Child With Attention Deficit/Hyperactivity Disorder”, ADHD is classified a ‘chronic condition’. When behavioral intervention does not meet target outcomes and effectively reducing ADHD symptomatology, then it does a disservice to every single child whose parents/guardians/physicians REFUSE to consider medication management.

    I am an adult with ADHD, and I would have been far better served to have had medication initiated when I was a child in school as opposed to the behavioral interventions that were supposed to help me to improve behaviorally and academically and insisted upon as the only resort available.

  • Ashley Says:

    to: For the Children
    Thank you for your comment; it brought much insight to the topic to help me better understand why these meds are so often prescribed vs. behavioral intervention. Its good to hear that coming from someone who is well aware of the condition due to personal experience.

    At the same time I feel that different people (considering their severity) would react to each treatment/med differently. So it seems to me that the best option would be to have a trial period of each treatment to see which proves to be most effective for that individual.

  • Dr. Robert Myers Says:

    To: For the Children: Thank you for your comments. The students you work with are very fortunate to have someone with the expertise and empathy you are able to share with them and their parents. We are certainly in agreement that a comprehensive approach to treatment which is tailored to the unique needs of each child is extremely important. Medication should always be made available to all that could benefit from it. The recent news articles I cited were making the case that evidence-based behavioral interventions should be readily available as well. Certainly other services, including special education and other school services should also be available. It is unfortunate that there are so many barriers to appropriate treatment, which result in the scenario you so accurately and passionately depicted.

    As stated above, I do not advocate a “one-size-fits-all” approach to treatment. Recommendation 3 in the American Academy of Pediatrics protocol states that stimulant medication should and/or behavior therapy should be employed and Recommendation 4 states that failure to achieve desirable results after behavior therapy and several different stimulants have been tried, a reassessment of diagnosis and adherence to the treatment plan should take place, as well as a possible referral to a mental health specialist. Recommendation 8 of the American Academy of Child and Adolescent Psychiatry states, “If none of the above agents (referring to stimulant and SNRI medications) result in satisfactory treatment of the patient with ADHD, the clinician should undertake a careful review of the diagnosis and then consider behavior therapy and/or the use of medications not approved by the FDA for the treatment of ADHD”.

    Finding the correct treatment takes the cooperation of a clinical expert, parent, school and child all working together as a team. Extra measures of patience and persistence are often required.

    I agree with Dr Jensen that “medication can make a make a long-term difference for SOME children.” However, I also agree with the statement that came from a conference of experts in the field of diagnosis and treatment of ADHD funded by the National Institute of Mental Health and conducted by the Hastings Center (quoted in my post) which points out that the initial MTA report found significant differences between treatments, while the 3 year follow-up found significant but the same degree of gain from all treatments, including behavioral treatment. This leads to the need to consider all treatment methods and find the one(s) that work best for each child.

    Finally, I would totally agree with the last line of the coverage of the Hastings conference in Child and Adolescent Psychiatry and Mental Health: “When families consider it necessary to enlist medical assistance in treating impairing behaviors, they should be carefully informed of the benefits and limitations of medication and behavioral therapy.”

    As an adult with ADHD and dyslexia, I wish they were prescribing medication and offering special education services back in the 50s when I was a school-age child. Having raised a son with ADHD (who did need medication as a young child, but also received behavioral interventions as well), I am happy these services are available and agree they should be easily available to all children as part of a comprehensive and individualized treatment program. I can attest as a child psychologist with over 25 years of clinical experience and as a parent of an ADHD child that proper treatment, along with a loving and encouraging family, can result in successful outcomes for these wonderful kids.

  • squashblossom Says:

    My observaiton is that in the area I live in young people are given meds, and no “talk therapy.”
    Our grandson is brilliant. He has a mother who is a seriously ill hoarder and no one who knows her would argue this.
    She wants him to “straighten his room”. He hates the meds and spits them down the sink; wherever he can.
    He does just fine with us.
    We do not insist onhim immediately cleaning up his room.
    The reason is we are taking it slow. This behavior did not happen overnight and we think it will take awhile.
    We ask him for cleanliness of body, clothing, hair, to brush his teeth, do his homework.
    I do not get crazy when I see clothing laying around.
    I realize since he has been staying with me that I have to go slow with changes.
    He says he feels safe with us.
    He knows he can talk about her condition with us.
    We personally think he should go to the counselor he is supposed to be seeing for his problems and tell that person about her condition.
    No one really knows about her house.
    How can he keep order should he have stayed there.
    Incidently, she brought him to us to live about 3 weeks before Christmas.
    She doesn’t understand how he can be happy with us.
    We want the counselor to treat them both.
    He is given vyanese, almost 70mg a day.
    When he takes it, he can’t stay at school. He falls asleep and the teacher sends him home.
    We have a desperate situation going on and no one to talk to.
    I tried one day to walk back to her room and see her and i couldn’t get thru to her room.
    That’s pretty bad. I did not raise her that way.
    She is 50 and he is 17, closer to 18.
    I remind her she may not have much power over him at 18 as to getting him to take these meds.

  • nlnugen Says:

    Unfortunately, a lot of school systems are driven that if the child is not on medication for ADHD, then they are not in such dire need of the training mentioned here. I feel, frmo personal experience with a child that requires medications (since the 3rd grade, he is now a Freshman in High school), and one that did not require medications, the one that was on medication got the better deal in school. He was given the attention, the training, the “extras” that the other was not given. So much for free and equal education.