Perhaps one of the biggest controversies surrounding attention deficit hyperactivity disorder (ADHD) focuses on one of its treatment options: Ritalin, the stimulant prescription drug with effects similar to cocaine. Unfortunately, the many other treatment options for this disorder frequently get lost in the uproar surrounding this medication.

In fact, a number of ADHD treatment options have proven to be effective for some children. Effective strategies include behavioral, pharmacological and multimodal methods.

Behavioral Therapy

Behavioral approaches represent a broad set of specific interventions that share a common goal: modifying the physical and social environment to alter or change behavior. They're used to provide structure for a child diagnosed with ADHD and to reinforce appropriate behavior. Behavioral approaches are typically implemented by parents as well as psychologists, mental health therapists, school personnel and primary care physicians.

Types of behavioral approaches include behavioral training for parents and teachers, in which the adult learns child management skills; a systematic program of contingency management, such as positive reinforcement, time-outs, response cost and token economy; clinical behavioral therapy, including training in problem-solving and social skills; and cognitive-behavioral treatment, such as self-monitoring, verbal self-instruction, development of problem-solving strategies and self-reinforcement. In general, these approaches are designed to use direct teaching and reinforcement strategies for positive behaviors and direct consequences for inappropriate behavior.

Behavioral strategies hold promise for children and their families dealing with ADHD. They may appeal to parents and professionals for these reasons:

• Behavioral strategies are used most commonly when parents don't want to give their child medication therapy
• Behavioral strategies can be used with medication therapy
• Behavioral techniques can be applied in a variety of settings, including school, home and the community
• Behavioral strategies may be the only options if the child has an adverse reaction to medication

This type of treatment does have some limitations, and research on the effectiveness of behavioral techniques is mixed. On the positive side, three separate studies found systematic programs of intensive contingency management conducted in specialized classrooms and summer camps with the setting controlled by highly trained individuals to be highly effective. Additionally, a 1998 study found parent training in behavior therapy and classroom behavior interventions to be successful in changing the behavior of children with ADHD, and interactions at home and school that support a consistent approach are important to the success of behavioral approaches.

While studies that compare the behavior of children during periods on and off behavior therapy demonstrate the effectiveness of behavior therapy, researchers have had difficulty isolating its effectiveness. Because so many different behavioral interventions and outcome measures exist, it's difficult to make careful analyses of the effects of behavior therapy alone or in association with medications. Although some research suggests behavioral methods offer the opportunity for children to work on their strengths and learn self-management, other research indicates behavioral interventions are less effective than medication therapy with stimulants.

Not surprisingly, then, behavior therapy has been found to be effective only when it is implemented and maintained. Unfortunately, implementing the strategies consistently across all settings for the therapy to be most effective can be difficult. Although behavioral management programs have been shown to enhance the academic performance and behavior of children with ADHD, follow-up and maintenance of the treatment is often lacking.

Some research has shown that behavioral techniques may fail to reduce ADHD's core characteristics: hyperactivity, impulsivity and inattention. That said, the problems of children with ADHD are seldom limited to the core symptoms themselves. Children frequently demonstrate other types of psychosocial difficulties, such as aggression, oppositional defiant behavior, academic underachievement and depression. Because many of these other difficulties cannot be managed through stimulant medications, behavioral interventions may be useful in addressing ADHD and other problems a child may be exhibiting.

Medication Therapy

Treating ADHD with prescription medication is one of the most common forms of ADHD treatment. While the rise of children taking Ritalin (methylphenidate) and other similar medications to manage ADHD is often attributed to a push by teachers to make difficult children easier to deal with in the classroom, the decision to prescribe any medicine is the responsibility of medical--not educational--professionals, after consultation with the family and agreement on the most appropriate treatment plan.

Medications prescribed to treat ADHD include stimulants, antidepressants, anti-anxiety medications, antipsychotics and mood stabilizers. Stimulants are the dominat class prescribed and have been found to be effective with 75 to 90 percent of children with ADHD. In addition to Ritalin, these drugs include Dexedrine (dextroamphetamine) and Cylert (pemoline). In January 2003, the FDA approved Straterra (atomoxetine), a new type of nonstimulant medication for treating children and adults with ADHD. The other classes of medication are used primarily for patients who don't respond to stimulants or who have coexisting disorders.

Although some critics of medication therapy for ADHD argue that the drugs simply lull children into complacency, the results of the Multimodal Treatment Study, first published in December 1999, confirmed previous research findings that medication therapy was almost as effective as the multimodal treatment of medication and behavioral interventions.

Treating a disorder characterized by hyperactivity with a stimulant drug might seem counterintuitive. Researchers believe stimulants affect the portion of the brain responsible for producing neurotransmitters, the chemical agents at nerve endings that help electrical impulses travel among nerve cells. Neurotransmitters are responsible for helping people pay attention to important aspects of their environment. The appropriate medication stimulates these underfunctioning chemicals to produce extra neurotransmitters, thus increasing a child's capacity to pay attention, control his or her impulses and be less hyperactive.

Although the positive effects of stimulant medication are immediate, all medications have side effects. Some of the more common side effects of ADHD medications include insomnia, nervousness, headaches and weight loss. In fewer cases, patients have reported slowed growth, tic disorders and problems thinking or interacting with others. Medication also can be expensive, depending on the medicine prescribed, the frequency of administration and the subsequent frequency of refills.

Stimulant medicines don't "normalize" the entire range of behavior problems, and children under treatment may still manifest higher levels of behavioral problems than their peers. Nevertheless, the American Academy of Pediatrics (AAP) finds that at least 80 percent of children respond to one of the stimulants if they are administered in a systematic way. Under medical care, children who fail to show positive effects or who experience intolerable side effects on one type of medication may find another medication helpful. The AAP reports that children who don't respond to one medication may respond to another medication and concludes that stimulants may be a safe and effective way to treat ADHD in children.