In the United States, medication is the first line of treatment for 90 percent of children with attention deficit hyperactivity disorder (ADHD). However, Florida International University (FIU) researchers have determined behavioral therapy—when used first—is more effective in treating children with ADHD than medication. It is also more cost-effective.
Their findings were recently published in two separate articles in the Journal of Clinical Child & Adolescent Psychology.
One study led by William E. Pelham Jr., a pioneer in the field of ADHD research and treatment, and director of FIU's Center for Children and Families, looked at the sequence of treatments—implementing behavior first compared to medication.
Results showed stimulants were most effective as a supplemental, second-line treatment option for those who needed it and at lower doses than typically prescribed. The year-long study enrolled 146 children ages 5 to 12 who had an ADHD diagnosis. Half were randomly assigned to receive a low dose of generic Ritalin. The other half received no medication, but parents attended training sessions to learn behavior-modification techniques based on a system of rewards and consequences. If after two months, a child had not improved, he or she was randomly assigned a more intense version of the same treatment or an added supplement, like incorporating a daily dose of medication to the behavior modification. The study is the first of its kind in the field to alter the types of treatment midcourse and evaluate the effects.
"We showed that the sequence in which you give treatments makes a big difference in outcomes," Pelham said. "The children who started with behavioral modification were doing significantly better than those who began with medication by the end, no matter what treatment combination they ended up with."
The second study addresses the cost-effectiveness of behavioral interventions as first-line treatment for ADHD. Led by FIU health economics expert Tim F. Page and co-authored by Pelham, this study compared the costs of the different treatment sequences, evaluating the cost of medication as well as the time invested by parents and doctors. Results showed the cost of a behavior-first approach was approximately $700 less annually than a medication-first approach.
"Prior work had found that medication was cheaper than behavioral therapy," Page said. "However, these studies were done before the introduction of extended release—and very expensive—medications. Our study shows that with the cost of the new medications, it is no longer the case that medication is cheaper than behavioral treatment."
If replicated in larger studies, the effectiveness of this behavior-first approach could revolutionize the standard practice of medicating first the more than 4 million children and adolescents diagnosed with ADHD in the United States.
"Our estimate is that health care costs for ADHD could be reduced by more than $4.5 billion annually in the country if doctors followed the behavioral treatment-first approach," Pelham said.
Pelham also serves as chairman of the FIU Department of Psychology. Page is associate professor in the Department of Health Policy and Management. The studies were funded by the Institute of Education Sciences and in part by grants from the National Institute of Mental Health, the National Institute of Alcohol Abuse and Alcoholism, and the National Institute on Drug Abuse.
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