If you’ve missed the headlines, here’s a quick summary: The U.S. Centers for Disease Control (CDC) has been promoting therapy before medication for young children with ADHD.
Sounds reasonable, eh? Except it’s not. I’m asking you to please empty your mind of what you think you know on this topic, and consider the actual facts.
A guest post below from Russell Barkley, PhD, explains the details. But first, some tidbits of overview.
Problems With CDC Stance on ADHD
1. Let’s clarify a common misunderstanding of the CDC guidelines: This therapy isn’t for the children, it’s for the parents. And it’s not a therapy that educates parents on ADHD and implementing ADHD-targeted strategies. It’s a very specific type of parent-training therapy, one that assumes the children are displaying disruptive behavior related to oppositional-defiance, not ADHD.
2. Never mentioned in the news reports: The existing research indicating that parental training of any type isn’t likely to “take” when the parents themselves have undiagnosed or poorly managed ADHD.
3. The CDC has no evidence that the type of therapy it is mandating actually works for children who have ADHD but without the complications of being oppositional or defiant. Moreover, there is evidence showing it does not work.
4. Journalists aren’t asking enough questions of the CDC and instead are running with its press releases, resulting in sensational headlines.
Here’s one from the Washington Post (historically the best paper when it comes to accurate reportage on ADHD): CDC warns that Americans may be overmedicating youngest children with ADHD.
It’s an accurate headline. The paper is not claiming the statement to be true. Rather, it simply attributes the statement to the CDC. Still, that’s not enough.
The fact is, many young children taking stimulant medication are also suffering from severe illness such as spina bifida. These are very sick children. I’ve seen no evidence that the CDC is taking these details into account. Certainly no news report indicates this.
5. This isn’t the first time that the CDC has sabotaged the public’s accurate understanding of ADHD, especially in young children.
Perhaps unwittingly but still quite damagingly, the CDC gave the New York Times‘ anti-ADHD reporter Alan Schwarz all the ammunition he needed to create a firestorm about “10,000 Toddlers Treated for ADHD. (I countered in this two-part post: Part I and Part II of The Truth Behind 10,000 Toddlers Medicated for ADHD.)
6. Could it be that the CDC has some political, or perhaps ideological, agenda here? I’m betting they aren’t as squishy on the science when it comes to, say, the Zika virus. (But the congressional GOP is refusing to fund CDC efforts on that front, so who knows what’s going on.)
Dr. Barkley on CDC ADHD Statement:
Anyone reading this article in Canady-2016-Mental Health Weekly, based on a report from and interviews with CDC officials, might draw this conclusion: Behavioral parent training (BPT) is as effective as medication for management of young children with ADHD.
Sadly, this simply is not true.
But it is yet another example of the CDC speaking to the press about their findings and implications without doing more careful scholarship or talking with those of us who do know the science on ADHD and its management.
First, understand that BPT was designed for and is most effective with helping parents manage oppositional, defiant, and noncompliant behavior in children.
It was not designed for—nor is it very effective in managing—the symptoms of ADHD specifically (inattention, impulsivity, hyperactivity, and executive function deficits).
Every meta-analysis of BPT for ADHD has found this to be the case, including the one in 2013 by Ed Sonuga-Barke and colleagues (Evidence-Based Psychosocial Treatment for Children and Adolescents with ADHD).
To be very clear: No major researcher working in ADHD, including myself, has ever claimed that BPT is effective for ADHD itself. Furthermore, we have known since the 1980s that BPT is not very helpful for ADHD symptom management.
BPT is based on social-learning theory and the idea that much of child misbehavior is the result of faulty learning and disrupted parenting. This type of therapy targets compliance and cooperation, not inattention and impulsivity.
Now, there is some truth to the involvement of parenting in the genesis and maintenance of oppositional, defiant, and noncompliant behavior in children. But there is no truth that parenting plays a similar role in ADHD.
Thus, from both a theoretical and practical viewpoint, BPT would not be expected to manage ADHD symptoms very well if at all.
What studies find with BPT is that parenting behavior improves but child symptoms improve very little; and when symptoms do improve, this improvement is not maintained after treatment (see here:http://www.sciencedirect.com/…/article/pii/S0891422212001278).
My own parent training books on Defiant Children make this point specifically in their introductory chapters. BPT is for ODD, not so much for ADHD symptoms.
The CDC should certainly have known this, given the findings of the Preschool ADHD Treatment Study (PATS)—a study conducted 10 years ago to assess the safety and effectiveness of stimulant medication for preschoolers with ADHD. This is the largest study ever done on this issue.
The study required that all children and their parents receive BPT before entering the medication trial. This is also precisely what the CDC is arguing for in the Health Weekly and other articles.
But here’s the key difference: In the study, the BPT was required so that only those whose ADHD symptoms did not respond to BPT could then get medication. What did researchers find? At least 55% of the preschool children still had to enter the medication trial because BPT didn’t help them much, if at all.
Don’t blame the Health Weekly writer, Canady, for this error. This and other publications are only reporting what they were told. It is the CDC professionals who should be blamed for this error. [Gina adds: Reporters at legitimate news outlets should be asking questions and soliciting outside opinions instead of simply running the CDC’s press releases and quotations from interviews with CDC officials. It is their role as watchdogs.]
For instance, Anne Schuchat, M.D. (pictured left), principal deputy director at the CDC, said during the briefing. “Behavior therapy has been shown to help improve symptoms in young children with ADHD and can be as effective as medicine but without the side effects.”
That is false! To state this is to show you do not know the actual literature on BPT for ADHD in children.
It also shows that Schuchat neither read the PATS study nor looked across the available reviews of the literature. The degree of improvement from BPT on ADHD symptoms is far below that seen in studies of medication. And even those effects of BPT on children are not sustained over time very well.
This is the crux of problem: Requiring that all young children undergo BPT first before being prescribed medication is to require that a less effective therapy be initiated before a more effective therapy (medication) is provided. Such statements from the CDC also lead one to believe that BPT is widely available in the U.S., when it is not.
It is no surprise that physicians are treating more young children with ADHD with medication than are getting BPT, as the CDC found. These physicians are leading with their most effective therapies first.
The CDC needs to stop making parents and physicians feel guilty about using medications to manage ADHD—and the CDC should certainly stop purveying the idea that BPT is as effective for ADHD children as medication. It just isn’t so.
Yes, parents should be encouraged to get BPT, especially if their child has oppositional defiant disorder, which many do. But don’t promise them that BPT will be as effective as medication because it won’t be. Tell them BPT is for reducing family conflict. Other interventions will need to specifically target the ADHD and EF symptoms, medication among them.
Gina’s Comment on Medscape’s Report
Interested in more on this topic?
As a subscriber to Medscape, I was chagrined to see this report a few weeks ago on the same CDC “talking points”: Behavioral Therapy for ADHD: Recommendations Ignored? (If you can’t see the article, click here.)
Here is the comment I posted in response:
I keep trying to figure out the CDC’s angle on ADHD.
Having had a lengthy discussion with a CDC contact on ADHD, I’m not even sure this person truly understands the nature of ADHD. Primarily, that it is a brain-based condition with myriad physical and cognitive effects, not simply a “behavioral” condition—also known as a “disruptive behavioral condition.”
Many children with ADHD are not disruptive; they are disrupted—by their ADHD symptoms.
I’d like for science and medical journalists to be asking more questions of the CDC, such as its data-collection methods used to support this conclusion (that more behavioral therapy should be taking place).
As for this, from Anne Schuchat, MD, principal deputy director for the CDC, said in a press briefing:
“What these data suggest is that we are missing opportunities for young children with ADHD to receive behavioral therapy, which can be just as effective as medicine but without the risk of side effects.”
Where is her proof? Nowhere. It does not exist. [As Dr. Barkley confirms above.]
At least Georgina Peacock, MD, MPH, director of the CDC’s Division of Human Development and Disability, clarifies that “behavioral therapy is a form of treatment in which parents learn specific ways to help improve their child’s behavior.”
To emphasize: The parents, not the children, receive the behavioral therapy.
Examine the various headlines associated with this story (originating with the CDC’s PR office) and count how many times this is made clear. Hardly ever.
Instead, the implication is that therapy is as important, if not more important, as medication for children with ADHD—as if therapy for the children would result in any improvement in their ADHD symptoms.
That false narrative only reinforces the public’s misperception that if people with ADHD, young or old, “knew better, they could do better.” Alas, “knowing better” does not mitigate brain-based distractibility, impulsivity, failure to consider consequences, and all the rest of ADHD symptomatology.
At any rate, guess what?
Given the genetics associated with ADHD, it’s almost a given that at least one of the biological parents has ADHD. And, unless that ADHD is well-managed, there’s little chance that behavioral training will “take” with that parent. (Yes, there is supporting research for this point. Psychologist Arthur Robin and I touch upon that in our new book, Adult ADHD-Focused Couple Therapy: Clinical Interventions.)
Finally, I’m not sure why alleged medical experts find it so hard to understand how a brain-based condition affecting dopamine transport and transmission could have adverse physical effects throughout the body, including with neurospatial coordination, hearing, vision, and even the ability to write legibly.
Ahem, dopamine controls many aspects of physiology.
We should be asking the CDC how it went about excluding from its dataset young patients receiving medication for ADHD who also have neural-tube defects, such as spina bifida. Or did the CDC exclude them? I’m betting not, as I alluded to in my counter to the New York Times “10,000 Toddlers” screed.
My suspicion—and I hope I’m wrong: The CDC is attempting to deal with the political backlash created by that and other articles written by the Times‘ grandstanding sports reporter, Alan Schwarz. For the “10,000 Toddlers” story, he’d snuck unannounced into a CDC presentation sponsored by the Carter Center in Georgia. Then, without benefit of neuroscience or any type of ADHD expertise, he crunched the data and presented it to the public as fact. There is a connection between that and this latest dictum from the CDC.
Overall, there seems to be something fishy going on at the CDC vis a vis ADHD.
Health journalists as well as medical experts should be making inquiries instead of unquestioningly running press releases. The lives and health of millions of people with ADHD in the U.S. hang in the balance. Do your job, watchdogs.