Reconsidering the role of medication in treating ADHD — Russell Barkley’s opinion

Russell Barkley is one of the world’s most renowned authorities on the diagnosis and treatment of ADHD.  He and other responsible, ethical behavioral scientists believe that the treatment of ADHD in children requires behavioral intervention, usually administered over a relatively long period of time (probably more than one year in most cases), in both the home and school in order to produce an effective and enduring impact on the child’s symptoms — and that medication may have a role in the treatment of ADHD as well.  While he acknowledges that medication has clearly been shown to be helpful in the treatment of ADHD, by no means does he or any other responsible, ethical behavioral scientist claim that medication alone is sufficient to treat ADHD and the remaining text of his essay underscores the fact that behavioral treatment is essential.  Barkley and other responsible, ethical behavioral scientists clearly disagree with Managed Care Organization “authorities” and their handlers who are insisting with increasing ardor in Pennsylvania that “The only evidence-based treatment for ADHD is medication, not Therapeutic Staff Support (TSS).” 

TSS is the delivery of intensive one-to-one behavioral treatment by a trained and supervised professional who works with the child in the home, school and community.  Evidence of the effectiveness of TSS service in the treatment of ADHD and Autism spectrum disorders (more than 1,000 cases, in fact) has been actively suppressed by those who would prefer it didn’t exist, but independent researchers from three different academic institutions (2007, 2010 and 2012) have documented statistically significant associations between TSS treatment by the staff of the Institute for Behavior Change and symptom reduction in children. 

The following text was taken from http://russellbarkley.org/content/adhd-facts.pdf                       October 15, 2012 

ADHD TREATMENT 

No treatments have been found to cure this disorder, but many treatments exist which can effectively assist with its management. Chief among these treatments is the education of the family and school staff about the nature of the disorder and its management, in the case of children with the disorder, and the education and counseling of the adult with ADHD and their family members. But among the treatments that results in the greatest degree of improvement in the symptoms of the disorder, research overwhelmingly supports the use of the stimulant medications for this disorder (e.g., methylphenidate or Ritalin, d-amphetamine or Dexedrine, Adderall, and, in rare cases, pemoline or Cylert). Evidence also shows that the tricyclic antidepressants, in particular desipramine, may also be effective in managing symptoms of the disorder as well as co-existing symptoms of mood disorder or anxiety. However, these antidepressants do not appear to be as effective as the stimulants. Research evidence is rather mixed on whether or not clonidine is of specific benefit for management of these symptoms apart from its well-known sedation effects. A small percentage of individuals with ADHD may require combinations of these medications, or others, for the management of their disorder, often because of the co-existence of other mental disorders with their ADHD.

Psychological treatments, such as behavior modification in the classroom and parent training in child behavior management methods, have been shown to produce short-term benefits in these settings. However, the improvements which they render are often limited to those settings in which treatment is occurring and do not generalize to other settings that are not included in the management program. Moreover, recent studies suggest, as with the medications discussed above, that the gains obtained during treatment may not last once treatment has been terminated. Thus, it appears that treatments for ADHD must often be combined and must be maintained over long periods of time so as to sustain the initial treatment effects. In this regard,  ADHD should be viewed like and other chronic medical condition that requires ongoing treatment for its effective management but whose treatments do not rid the individual of the disorder [emphasis added]. Some children with ADHD may benefit from social skills training provided it is incorporated into their school program. Children with ADHD are now eligible for special educational services in the public schools under both the Individuals with Disabilities in Education Act (IDEA) and Section 504 of the Civil Rights Act.

Adults with ADHD are also eligible for accommodations in their workplace or educational settings under the Americans with Disabilities Act provided that the severity of their ADHD is such that it produces impairments in one or more major areas of life functioning and that they disclose their disorder to their employer or educational institution. Adults with the disorder may also require counseling about their condition, vocational assessment and counseling to find the most suitable work environment, time management and organizational assistance, and other suggestions for coping with their disorder. The medications noted above that are useful for children with ADHD have recently proven to be as effective in the management of ADHD in adults.

Treatments with little or no evidence for their effectiveness include dietary management, such as removal of sugar from the diet, high doses of vitamins, minerals, trace elements, or other popular health food remedies, long-term psychotherapy or psychoanalysis, biofeedback, play therapy, chiropractic treatment, or sensory-integration training, despite the widespread popularity of some of these treatment approaches.

The treatment of ADHD requires a comprehensive behavioral, psychological, educational, and sometimes medical evaluation followed by education of the individual or their family members as to the nature of the disorder and the methods proven to assist with its management [emphasis added].  Treatment is likely to be multidisciplinary, requiring the assistance of the mental health, educational, and medical professions at various points in its course. Treatment must be provided over long time periods to assist those with ADHD in the ongoing management of their disorder. In so doing, many with the disorder can lead satisfactory, reasonably adjusted, and productive lives.

Adapted from R. A. Barkley & K. R. Murphy (2006) Attention deficit hyperactivity disorder: A clinical workbook (3rd ed.). New York: Guilford Publications. Copyright 2006 by Guilford Publications. Reprinted with permission. This clinical workbook has numerous forms, interviews, and rating scales that can be helpful to clinicians in their clinical practice. To order, go to our Products page in the Directory.

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Peter R. Breggin, MD — often described as “The Conscience of Psychiatry” — has also weighed-in (for more than a decade) against the reliance upon stimulant medication in the treatment of ADHD, especially in the United States.  He noted many years ago, for example, that of the 9 million children who were receiving Ritalin in the world, 8 million lived in the US.  His two-page synopsis of research conducted prior to 2000 indicating that stimulant medications may be producing psychotic symptoms in children at a level much greater than is typically reported can be read here:

http://www.breggin.com/index2.php?option=com_docman&task=doc_view&gid=29&Itemid=37

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Conclusion:  When Behavioral Health Rehabilitation Services (BHRS, often mistakenly called “wraparound services” in Pennsylvania) are used to treat ADHD symptoms in the home, school and community of the child, applying the principles of “High Fidelity Wraparound” and Applied Behavior Analysis, effective treatment of ADHD occurs.  This is the model that staff of the Institute for Behavior Change have been implementing since 1997 and can be implemented whether or not a child is receiving stimulant medication.  Visit www.ibc-pa.org and www.TreatmentPlansThatWorked.com for more information about this.

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