Education World explores research that has studied various treatments of ADHD, including medication, behavioral intervention, and neurofeedback.
Treating hyperactivity with stimulant medication isn't something new. Back in the 1930s, according to many medical and psychiatric associations, physicians prescribed amphetamines to help hyperactive individuals.
The combined treatment is also supported by Children and Adults With Attention-Deficit/Hyperactivity Disorder (CHADD), a nonprofit organization that provides support for parents and advocates more research.
Although stimulant medication, along with psychosocial intervention, has been found to be the best way to help children with ADHD, treatment may not normalize the entire range of behavior problems. Two years ago, the NIH held a conference at which a group of researchers and clinical practitioners discussed ADHD and its treatment; the group then issued the consensus statement Diagnosis and Treatment of Attention Deficit Hyperactivity Disorder. The statement reports that stimulant medication improved the core symptoms of children who had ADHD but did not change academic achievement or social skills. But parents and teachers see that the combined treatment results in improved social skills, according to the consensus report.
Another advantage of adding behavioral intervention to an ADHD child's treatment is that by improving the child's functioning, the amount of medication may be reduced, according to the experts convened for the NIH conference. According to those experts, psychosocial treatment of ADHD has included a number of behavioral strategies. Contingency management strategies often used by teachers in the classroom include point or token reward systems and timeout. Psychosocial treatment can also include teaching parents child management skills and clinical behavior therapy when a parent, teacher, or both are taught management procedures.
Generally, intensive direct-intervention with children with ADHD in school and at home produces improvements in key areas of functioning. However, studies that compare stimulants with psychosocial treatment report better results with stimulant treatment.
A concern raised by experts at the NIH consensus program is that most research has evaluated children with what is considered to be the most severe type of ADHD, the type that includes both inattention and hyperactivity. There are two other types of ADHD: inattention without hyperactivity and hyperactivity without inattention. Although those experts found that stimulant treatment was superior for children with the combined type of ADHD, the research had not separated the types of ADHD, they said.
In response to those concerns, the NIMH invited research grant applications for Developing, Testing and Implementing Innovative Interventions for ADHD. One of the specific requests calls for highly focused research to focus on how children with different symptom profiles and needs respond to different types of interventions.
As more data are collected about treatments for the three different types of ADHD, some experts believe there will be more of a distinction made between those subtypes.
"The nature of the problems is different," said Howard Abikoff, the Pevaroff Cohn professor of child and adolescent psychiatry and director of research and professor of child and adolescent psychiatry at the New York University Child Study Center. "My hunch is that down the road, the inattentive subset will be separated out and viewed as its own disorder."
Although much controversy about ADHD pertains to the number of children and adolescents using psychotropic medication, there are even more concerns about preschoolers using that same type of medication. A key worry is that there are no long-term studies evaluating the safety of using psychotropic drugs with young children. Most of the uneasiness about this age group's use of psychotropic medication relates to little or no proven efficacy for very young children, according to a study, Trends in Prescribing of Psychotropic Medications to Preschoolers.
For that very reason, the NIMH has funded a $5 million, three-year, six-site study to evaluate 300 children, ages three to five years, and compare them with children ages 6 to 8 years who are also using stimulant medications. An additional $2.5 million will fund the research sites, according to the NIMH.
The researchers have been designing this study for more than two years, Abikoff said. The study will try to answer whether the use of stimulant medication by young children is a good thing or a bad thing, he said. Researchers will evaluate numerous details about stimulant medication, including how effective it is, what the best doses are, what the side effects are, and how the children benefit over a long period of time.
Many treatments other than psychotropic medication and psychosocial treatment are being used to treat attention deficit hyperactivity disorder. Those treatments include dietary management, herbal and homeopathic treatments, biofeedback, meditation, and perceptual stimulation/training. However, according to the American Academy of Pediatrics, those alternative treatments are unproven. One reason that alternative treatments are unproven is there have not been many rigorous, scientifically designed longitudinal studies of them.
There have been some promising results with studies of biofeedback, sometimes called neurofeedback; however, those studies have used very small samples, so that treatment also has not been proved by rigorous scientific standards.
Neurofeedback is a method of learning to modify behavior or other physiological functions by monitoring with an electronic device. The premise is that children with ADHD can alter an agitated state by learning how to change brain wave patterns.
"[The NIMH] never say neurofeedback doesn't work," said Jonathan Michaelis, clinical neuropsychologist and director of the ADD Centers in Connecticut. Michaelis, who attended Surgeon General David Satcher's conference on ADHD this September with 500 other practitioners and ADHD experts from across the nation, advocates neurofeedback.
Michaelis said that 80 percent of the children who undergo 30 to 40 biofeedback sessions are able to get off medication, improve their IQs, and improve their overall functioning as well. Currently, the only child study funded by the NIMH pertaining to biofeedback is exploring autism.
Biofeedback isn't new, however. M. Barry Sterman, professor emeritus at the School of Medicine of the University of California (Los Angeles), first developed it 40 years ago. Although Sterman and others have been studying the use of biofeedback to treat ADHD children for many years, it is considered an unproven treatment.
"These alternative treatments, be they neurofeedback or other approaches, must be evaluated in controlled clinical trials," said Abikoff, the director of research at the New York University Child Study Center. "Only when they have gone through rigorous scientific testing, and when findings of effectiveness have been replicated, should these approaches be considered as possible treatments for ADHD."
Children and Adults With Attention-Deficit/Hyperactivity Disorder (CHADD) stands behind treatments that have been found to be effective through rigorous, scientific research, said Beth Kaplanek, volunteer president of CHADD's board of directors. "Neurofeedback is still considered a controversial treatment because it has not had the full gamut of rigorous, scientific testing," she told Education World. "That doesn't mean it doesn't work. As a mother of an ADHD child and CHADD chapter coordinator, [I can tell you] neurofeedback works with some. But some of the alternative treatments are way out there in left field," Kaplanek said. "We have a need to look at all aspects of treatment."
There are many critics of the current treatment recommendations by the medical, educational, and psychological/psychiatric establishments. Several books have been published about the problems of using medication instead of focusing on cultural and education improvements to help ADHD children.
One of those critics is Thomas Armstrong, author of ADD/ADHD Alternatives in the Classroom (Association for Supervision and Curriculum Development, 1999). Armstrong is an educator and psychologist in California who wrote this book because he wants parents, schools, and researchers to ask deeper questions and develop broader strategies to help children with ADHD. He advises teachers to focus on the positive attributes of a child who has ADHD by embracing his or her learning styles and strengths.
Employing creative, hands-on activities that focus on student projects is one alternative remedy to improving ADHD students' academic performance, Armstrong suggests. Research suggests that ADHD students do better in active, self-paced, hands-on classroom environments that use video games and computers and that correspond to an ADHD's child high-speed behavior and thinking.
"I felt that the thing missing from learning disability work was the focus on what kids could do," Armstrong told Education World. "Why are we using a disease-based paradigm and not an education paradigm?" Armstrong asks. Much of the work and treatment in the field of ADHD looks at the issue from an external perspective, he said. Though Armstrong doesn't argue that the current medication and behavior modification treatments are effective for many children, he suggests teachers, researchers, and parents need to consider what these children can accomplish, not just look at their deficits.
Armstrong said teachers should understand how children go through natural attention cycles and focus on their students' other types of intelligences. By doing this, there would be a shift from what the child can't accomplish to what the child can do.
Diane Weaver Dunne
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