Hyperactive Kid? Help the Parents

ADHD treatment involving parent training was more effective than medication

March 31, 2013 / Author:  / Reviewed by: Robert Carlson, M.D

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(dailyRx News) If a child shows signs of a problem like ADHD, addressing it early is the best course of action. But what's the most effective way to address this behavior issue in preschoolers?

A recent study reviewed the evidence for a variety of different methods for addressing children's attention deficit hyperactivity disorder (ADHD).

The researchers found that parent behavior training has stronger evidence for how well it treats ADHD in preschool children than medication has.

The parent behavior training also did not have negative side effects like the medication did. It also encouraged a stronger relationship between the parent and the child.

"Talk to your pediatrician about ADHD risk."

The study, led by Alice Charach, MD, MSc, of the Department of Psychiatry at the University of Toronto in Canada, looked at the research on different methods of treatment for children with ADHD.

The researchers gathered all the studies from 1980 to November 2011 from five different medical research databases that met their criteria. They sought studies that involved children under age 6 with "clinically significant disruptive behavior, including ADHD."

The studies needed to compare different treatments for the children in order to be included in this review. A total of 55 studies were included in the final analysis.

The different types of treatment reviewed in these studies were parent behavior training, combined home and school/daycare interventions and methylphenidate, a medication commonly known by brand names like Ritalin and Concerta.

Parent behavior training is an intervention in which parents learn how to "manage their children's problem behaviors with more effective discipline strategies by using rewards and non-punitive consequences."

In other words, parents learn to reward children for good behavior and to use consequences for poor behavior rather than punishment. One goal of parent behavior training is to "promote a positive relationship between parent and child."

Parent behavior training also teaches parents about common problem behaviors in children and common developmental issues they may face. The effectiveness of parent behavior training is measured through improvements in children's behavior and in the parents' parenting skills.

The researchers pulled the data from all the studies to analyze it as one large group, but only studies looking at the effectiveness of parent behavior training had sufficient data for adequate conclusions.

The eight high-quality studies that looked at parent behavior training included 424 children total and showed strong evidence for the effectiveness of this treatment.

The 15 studies which looked at medication treatment primarily compared methylphenidate or a similar medication to a placebo, or fake pill. All of these studies showed improvement in the children's ADHD symptoms, but only one of these studies, which included 114 children, was high quality enough to be included in the final data analysis.

The researchers therefore did not have sufficient evidence to determine how effective treatment with medication could be compared to other forms of treatment for ADHD.

However, the evidence did show negative side effects in children taking methylphenidate and other medications, whereas the parent behavior training treatment did not have negative side effects for the children.

The most common side effects the children taking methylphenidate experienced were poor appetite, social withdrawal, lack of alertness, stomachache and irritability. These were more common at higher doses of the medication than at lower doses.

"In general, most parents and clinicians prefer to avoid the use of medications in such young individuals if possible, and the scant evidence available on methylphenidate in this population suggests it is less effective and has more side effects than is true for older children with ADHD," said dailyRx expert Glen Elliott, MD, PhD, a clinical professor at the Stanford University Department of Psychiatry and Behavioral Sciences.

However, he cautions that these findings do not mean medication has no value in treating ADHD.

"The unfortunate aspect of these authors’ conclusion is that it may lead parents to believe that the only effective treatment is a behavioral modality that is not all that widely available," he said. "We know that behavioral approaches are highly effective, but, like medications, they need to be sustained, which some/many families find difficult."

The research that involved different types of interventions at home and school or daycare combined did not show consistent results across the studies.

"The issue of how best to intervene with preschool children with severe behavioral disruptions remains vexing," Dr. Elliott said.  "As these reviewers note, literature in this area is sparse, reflecting among other things the difficulty of doing well-controlled studies in this population."

The researchers of this study concluded that the available studies out there showed more evidence for the effectiveness of parent behavior training than for methylphenidate medication among preschool-aged children.

Yet, Dr. Elliott notes that no treatment is a cure, and treatment needs may change for children as they grow up.

"ADHD is a chronic disorder, with specific problem areas and approaches to treatment changing over time," Dr. Elliott said. "None of the available treatment approaches actually 'fix' the underlying problem, although they can greatly alleviate the disruption and chaos these children can create and enable them to develop in other aspects of their lives."

These findings do not mean that the medication didn't not work. Rather, more high-quality research had been done on parent behavior training than on the medication, and that research showed positive results for that treatment type in addressing ADHD in preschool children.

These findings also showed that parent behavior training methods do not have the negative side effects that can occur with methylphenidate.

The study was published April 1 in the journal Pediatrics. The research was funded by the US federal Agency for Healthcare Research and Quality in Rockville, Maryland. The authors reported no conflicts of interest.