Nonpharmacological ADHD Treatments for Youths: How to Implement Evidence-Based Practice Recommendations

TABLE: Evidence-based ADHD psychotherapies, references, and manuals

There are countless examples of long-lasting ongoing rivalries that most likely will never be totally settled, such as Coke versus Pepsi. No one would think that these 2 could ever work together for the common good. But what about therapy versus medication? Is there a conflict between these 2 treatment approaches? Uncompromising proponents exist for the solo use of either methodology: one camp argues that the risk of adverse effects is not acceptable, and the other that psychosocial interventions have very little benefit compared with their expense. Since no single remedy exists that is 100% successful, clinicians often recommend a combined approach.

Clinical studies and surveys of whether to use one or the other approach, or a combination of both abound. Huhn and colleagues¹ undertook a large review of 61 meta-analyses containing 852 trials and 137,126 participants to assess the efficacy of pharmacotherapies and psychotherapies for major psychiatric disorders. In head-to-head comparisons, they found that pharmacotherapy was more effective for dysthymia and schizophrenia, but psychotherapy was better for bulimia and prevention of depression relapse. A combination of pharmacotherapy and psychotherapy was significantly more effective than psychotherapy alone as treatment for MDD, social phobia, and bulimia. And a combination of psychotherapy and pharmacotherapy was superior to pharmacotherapy alone for depressive disorder, schizophrenia, panic disorder, and bulimia.

[[{"type":"media","view_mode":"media_crop","fid":"41276","attributes":{"alt":"© Emilio100/shutterstock.com","class":"media-image media-image-right","id":"media_crop_6642594294089","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4333","media_crop_rotate":"0","media_crop_scale_h":"143","media_crop_scale_w":"150","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"©Emilio100/shutterstock.com","typeof":"foaf:Image"}}]]In the lay press, according to a survey of 3079 of its readers, Consumer Reports² found that a combination of talk therapy and drugs often worked best. “Mostly talk” therapy was almost as effective if it lasted for 13 or more visits. “Mostly drug” therapy was also effective for many individuals. Drugs had a more rapid impact on symptoms than talk therapy, but it took time to find the right medication.

Official government communications such as those issued by the National Institutes of Health assert that “sometimes medications are used with other treatments such as psychotherapy and that psychotherapy alone may be the best treatment for a person, depending on the illness and its severity.”³

In ADHD, the issue of medication versus therapy remains, and it is not surprising that this issue is still not resolved. Almost 80 years have passed since the publication of the seminal paper by Bradley⁴ that marked the beginning of psychopharmacology for children and adolescents with ADHD. Since then, a very large body of literature has validated that pharmacology is a first-line, safe, and effective treatment for ADHD in youths. Consequently, after a diagnosis of moderate to severe ADHD, clinicians feel comfortable recommending medication and explaining to families the risks and benefits of the proposed treatment.

Pediatricians and child psychiatrists are, most often, treatment providers to youths who have ADHD. Their professional associations have issued somewhat different practice guidelines regarding the medication versus therapy dilemma. In 2011, the American Academy of Pediatrics (AAP) took an inclusive, age-dependent approach⁵:

• For preschoolers, behavioral therapy is favored

• For children aged 6 to 11 years, the AAP recommends medication or behavior therapy and preferably both

• For adolescents, the clinician should prescribe medication and may prescribe behavioral therapy; a combination of both is preferable

On the other hand, the American Academy of Child and Adolescent Psychiatry’s (AACAP) 2007 parameters tend to favor medication: “It seems established that a pharmacological intervention for ADHD is more effective than a behavioral treatment alone. Behavioral therapy may be recommended as an initial treatment if the patient’s ADHD symptoms are mild with minimal impairment, the diagnosis of ADHD is uncertain, parents reject medication treatment, or there is marked disagreement about the diagnosis between parents or between parents and teachers.”⁶

A 2015 report suggests that the AACAP guidelines are followed more closely than those of the AAP.⁷ The authors analyzed the responses of a very large US Centers for Disease Control and Prevention parental survey regarding children aged 4 to 17 years about the presence of an ADHD diagnosis and its treatment. It was found that, of those youths with ADHD, 43.3% received medication only, 30.7% received a combination of medication plus therapy, 13.3% received therapy only, and 12.7% were not treated.

Randomized clinical trials (RCT) for pharmacology have been used for years; in contrast, psychotherapy research only began using RCTs very recently. Although RCTs are a gold standard, they are more difficult to employ in psychosocial research for several reasons: double-blind conditions are not practical, intensive investigator training using treatment manuals has to be implemented in order to guarantee treatment fidelity, and the duration of treatment has to be of significant length to demonstrate change. An extraneous factor that has played an important role in influencing psychotherapy outcome studies is that the “same” therapy performs better in studies conducted by researchers who are committed to the approach than it does in studies conducted by others, a factor also known as “therapist allegiance.”⁸ Therapist allegiance affects outcomes and needs to be considered when interpreting results.

The family declined medication-now what?

While the role of the physician is to guide, counsel, and advise, ultimately it is the family’s responsibility to decide which treatment should be pursued. The issues of whether medication is more effective than therapy or whether therapy is effective as a single modality are not addressed in this article; instead, the article aims to provide psychiatrists with practical tips on how to proceed with the treatment recommendation process with families who prefer therapy alone.

To remain true to evidence-based principles, the psychiatrist must follow a path that goes beyond simply recommending “therapy.” In other words, once a family declines medication (patient preference), the psychiatrist has to select the type of psychotherapy with the best research results (evidence) that they are skilled in (expertise). Since it appears that more than half of psychiatrists no longer practice psychotherapy, the recommendation process will also likely involve a referral to an outside therapist with expertise in the suggested approach.⁹ The psychiatrist must be familiar not only with the most effective therapies for ADHD but also with how to find an appropriate therapist if he or she will not be the treating clinician.

A number of psychotherapy approaches for ADHD demonstrate evidence-based effectiveness. It is generally accepted that stimulants reach an effect size of about 1.0 for the treatment of ADHD core symptoms. Less agreement exists regarding the effect size of behavioral interventions: some meta-analyses propose an effect size approximately as high as 0.83 for between-group studies while others show no efficacy.^10,11 This large gap in findings probably results from methodological differences in how the meta-analyses were conducted. For instance, inclusion of non-RCTs favors an increase in effect size. Another consideration is that behavioral interventions have tended to show better efficacy for overall functional improvements (parents are more pleased) rather than improvements in specific core ADHD symptoms (attention, hyperactivity, impulsivity).¹² The Table lists the types of psychotherapies with the best chances of success; each is linked to a review paper that the reader can consult for a comprehensive appraisal, and to a manual that can be used to develop expertise in the technique.

Therapies that work

Behavioral modification and social skills training (SST) approaches have been the most studied and utilized modalities for decades. The most common behavioral intervention involves training parents for 8 to 12 sessions in contingency theory, during which they learn basic principles of how to reward good and extinguish undesired behaviors. Once proficient with a home approach, parents can extend and coordinate their efforts with cooperative teachers to institute daily report cards that link improvement in school behaviors to rewards at home, thereby extending the reach of the approach to the school setting without having to demand a change in school processes. Specific school-based behavioral interventions are effective but much more difficult to implement given the lack of educational resources.

Another fairly successful approach is centered on having patients improve the manner in which they relate to peers, which is significantly deteriorated in ADHD. SST teaches children to overcome deficits in sharing, making conversation, meeting new friends, taking turns when playing, following game rules, and walking away when upset. These skills are best taught in group settings so that children can practice with peers. Faraone and Antshel¹³ provide information on SST as well as other therapies such as cognitive therapy, neuropsychologically informed therapy, and others.

Practical tips for locating a therapist

For those psychiatrists who are not proficient in effective therapies and do not have the time to learn the methodologies of the therapies, the next step is to find an expert clinician they can refer their patient to. The previously mentioned therapist allegiance effect is relevant not only to better understanding of research results.⁸ Predictably, therapists with specific expertise and investment in the modalities they profess will be more effective; thus, the treating clinician needs to be invested in the modality being used and have experience with it.

Many psychiatrists have already established ongoing referral relationships with able therapists, but for those who have not, the search engines of several websites can quickly help find a suitable therapist. The Association for Behavioral and Cognitive Therapies (ABCT) is an interest group of mental health professionals (it is not a certifying organization).¹⁴ The association makes its list of members and specialties available via a search page to help locate a therapist. Query parameters include location, patient age, individual versus family, and over 100 clinical conditions, among which ADHD can be found. The type of insurance accepted can also be checked, which is very helpful because a clinician may have opted out of the insurance system or does not accept whatever insurance the patient has. When parameters of zip code 10028, within a 20-mile radius, for children with ADHD, and family therapy were entered, the search engine yielded the names of 3 therapists. There is a detailed profile associated with each therapist, including contact information.

Members of the American Psychological Association (APA)must have a doctoral degree in psychology or a related field from a regionally accredited graduate or professional school or a school that achieved such accreditation within 5 years of the doctoral degree.¹⁵ The APA does not certify that the therapist is qualified in specific treatment modalities, but it offers a search engine (although it does not list insurance status). Using the same parameters as for ABCT, the query yielded 131 therapist profiles. In some cases, there was a brief summary with varying degrees of information attached to the profile.

According to its website, the National Association of Cognitive-Behavioral Therapists (NACBT)is the leading organization dedicated exclusively to supporting, promoting, teaching, and developing cognitive-behavioral therapy and those who practice it.¹⁶ In contrast to the other organizations, NACBT lists only therapists who have obtained certification with the association. The criteria for certification are listed on the website. The search engine allows searching for therapists by state only. The state of New York had 8 therapists listed, each one accompanied by a brief profile.

Finally, Psychology Today has a therapist search engine that finds professionals from various backgrounds who specialize in treating ADHD.¹⁷ According to the publication, it verifies the name and contact details of the professional; that the professional’s license, if applicable, is valid within the state in which he or she practices; and that the professional is not subject to any license strictures preventing practice. However, the site cautions that the integrity of the directory relies on its professional membership and that professionals pay a fixed monthly fee to participate.

Conclusion

Despite the significant safety and effectiveness of pharmaceutical agents for the treatment of ADHD, many families decline this recommendation and request psychotherapeutic alternatives. There are several evidence-based psychotherapeutic approaches that may prove effective; however, outcomes depend on the experience of the treatment provider.

Disclosures:

Dr Kaplan is Clinical Associate Professor of Psychiatry at the Rutgers New Jersey Medical School, Newark, NJ, and Medical Director, Behavioral Health Services at the Bergen Regional Medical Center, Paramus, NJ. He reports no conflicts of interest concerning the subject matter of this article.

References:

1. Huhn M, Tardy M, Spinelli M, et al. Efficacy of pharmacotherapy and psychotherapy for adult psychiatric disorders: a systematic overview of meta-analyses. JAMA Psychiatry. 2014;71:706-715.

2. Consumer Reports. Drug vs talk therapy. http://www.consumerreports.org/health/free-highlights/manage-your-health/depression/talktherapy.htm. Published October 2004. Accessed August 24, 2015.

3. National Institute of Mental Health. Transforming the understanding and treatment of mental illness. http://www.nimh.nih.gov/health/topics/mental-health-medications/mental-health-medications.shtml. Accessed August 24, 2015.

4. Bradley C. The behavior of children receiving benzedrine. Am J Psychiatry. 1937;94:577-585.

5. American Academy of Pediatrics. ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2011; 128:1007-1022.

6. Pliszka S, for the AACAP Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2007;46:894-921.

7. Visser SN, Bitsko RH, Danielson ML, et al. Treatment of attention deficit/hyperactivity disorder among children with special health care needs. J Pediatr. 2015;166:1423-1430.

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12. Faraone SV, Antshel KM. Towards an evidence-based taxonomy of nonpharmacologic treatments for ADHD. Child Adolesc Psychiatr Clin N Am. 2014; 23:965-972.

13. Faraone SV, Antshel KM. ADHD: non-pharmacologic interventions. Child Adolesc Psychiatr Clin N Am. 2014;23:13-14.

14. The Association for Behavioral and Cognitive Therapies. http://www.abct.org/Home/. Accessed August 24, 2015.

15. Practice Central. Psychologist Locator. http:// locator.apa.org/. Accessed August 24, 2015.

16. National Association of Cognitive-Behavioral Therapists. http://www.nacbt.org/searchfortherapists. ASP. Accessed August 24, 2015.

17.Psychology Today. Find a therapist. https:// therapists.psychologytoday.com/rms//. Accessed August 24, 2015.

18. Pfiffner LJ, Haack LM. Behavior management for school-aged children with ADHD. Child Adolesc Psychiatr Clin N Am. 2014;23:731-746.

19. Barkley RA. Defiant Children: A Clinician’s Manual for Assessment and Parent Training. 3rd ed. NY: Guilford Press; 2013.

20. Robin AL. Family therapy for adolescents with ADHD. Child Adolesc Psychiatr Clin N Am. 2014; 23:747-756.

21. Barkley RA, Robin AL. Defiant Teens: A Clinician’s Manual for Assessment and Family Intervention. 2nd ed. NY: Guilford Press; 2014.

22. Mikami AY, Jia M, Na JJ. Social skills training. Child Adolesc Psychiatr Clin N Am. 2014;23:775-788.

23. Gallagher R, Abikoff HB, Spira EG. Organizational Skills Training for Children With ADHD: An Empirically Supported Treatment. NY: Guilford Press; 2014.