Few children with ADHD get behavioral therapy

A study found that children who take ADHD medication get little psychotherapy or behavioral treatment to complement their medication.

Few children who take medication for attention-deficit/hyperactivity disorder (ADHD) also undergo behavioral therapy, and the rates vary six-fold across counties in the United States, a new study finds.

Medication alone can manage symptoms for many children with ADHD, but some do better if they also receive behavioral therapy (psychotherapy), the Rand Corp. researchers noted.

The researchers analyzed data in more than 1,500 counties across the United States that included more than 300,000 privately insured children, aged 17 and younger, who were prescribed ADHD drugs. Less than a quarter of them received any psychotherapy in the same year they took ADHD medications; 13 percent had at least four therapy visits, and seven percent had at least eight therapy sessions.

In some counties, fewer than 10 percent of kids taking ADHD drugs got behavioral therapy, according to the study, which was published as a research letter in the Sept. 22 issue of the journal JAMA Pediatrics.

Those who lived in counties with fewer licensed psychologists were less likely to receive psychotherapy while taking ADHD drugs, the data showed. But even in some counties where the number of psychologists were the same, the rates varied.

In California's Sacramento County, almost half the kids with ADHD received therapy along with drugs, compared to only about 20 percent of those in Florida's Miami-Dade County, the researchers noted.

"Treatment of ADHD in children generates lots of controversy, primarily because of potential for overuse and abuse of stimulant medications," study author Dr. Walid Gellad, an adjunct scientist at Rand, said in a news release from the nonprofit research organization.

"We wanted to find out among those who receive ADHD medications, how many are also receive billed psychotherapy services? The answer is few, but it actually depends on where you live," Gellad said.

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Behavior-focused therapies and autism

This review discusses the benefits of behavior-focused therapies for children with autism.

Vanderbilt researchers this week reported updated findings regarding the benefits of behavior-focused therapies for children with autism spectrum disorder (ASD).

The review, conducted by the Agency for Healthcare Research and Quality (AHRQ)-funded Vanderbilt Evidence-based Practice Center (EPC), updates a prior systematic review of interventions for children (up to age 12) with a focus on recent studies of behavioral interventions.

Study authors said the quality of research studies has improved dramatically since AHRQ's 2011 review of studies on ASD, when authors reported that there were significant gaps in research available to document the benefits of treatments.

The updated review examined published evidence regarding the effectiveness of early intensive behavioral and developmental interventions -- interventions with a primarily behavioral approach based on applied behavioral analysis (ABA) principles and a comprehensive focus targeting multiple areas of functioning.

"We are finding more solid evidence, based on higher quality studies, that these early intensive behavioral interventions can be effective for young children on the autism spectrum, especially related to their cognitive and language skills," said lead author Amy Weitlauf, Ph.D., assistant professor of Pediatrics and a Vanderbilt Kennedy Center investigator. "But the individual response to these treatments often varies from child to child."

"We are also finding evidence that some of these targeted interventions, especially related to cognitive treatments for anxiety disorders, are also very effective for many, many children. Again, responses vary substantially and there are some children for whom these treatments have not yet been studied. So there is lots of promising evidence that these interventions are helpful, but we definitely need more research on which kids the treatments are more helpful for over time," Weitlauf said.

In previous decades ASD was often thought to be almost untreatable, said senior author Zachary Warren, Ph.D., director of the Vanderbilt Kennedy Center's Treatment and Research Institute for Autism Spectrum Disorders (TRIAD).

But researchers, clinicians and parents have increasingly documented impressive improvements in early cognitive, language and educational outcomes for some children with ASD receiving intervention.

Research results were not as strong in terms of improving broad developmental outcomes of children with ASD when interventions focused on training parents to use behaviorally based approaches with their children, but the interventions did show positive effects on parenting behaviors, on interactions between parents and children and on communications skills for some children.

"Given the potential for interventions to powerfully improve children's quality of life, in combination with the significant costs and resources often associated with treatment, it is not surprising that many groups -- parents, providers, policymakers, insurance providers -- are searching for an enhanced understanding of which interventions work the best for children with ASD," said Warren, associate professor of Pediatrics, Psychiatry and Special Education.

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What should I know about circadian rhythm sleep disorders?

This article details what everyone should know about circadian rhythm sleep disorders. People can have complaints of insomnia or excess sleepiness, depending on the problem with their life. - JR

When we think of sleep disorder, we tend to think of insomnia, but there are other sleep disorders that can affect a person's ability to work, attend school or live a normal life.

Your circadian rhythm is your body's "internal clock," which signals when you should sleep and when you should wake, as well as other body processes. Normally, this clock runs on a 24-hour cycle, which echoes the Earth's pattern of night and day. We sleep at night; we are awake during the day. However, sometimes our circadian rhythm becomes disrupted, making it difficult for people to sleep during the night or be fully awake and functioning during the day.

Some common causes are going on shift work, pregnancy, time zone changes, medications and changes in routine.

Some common circadian rhythm disorders are:

Jet lag or rapid time zone change syndrome: This includes excessive sleepiness and lack of daytime alertness in people who travel across time zones.

Shift work sleep disorder: This sleep disorder impacts those who frequently have to rotate work shifts or often work at night. They may have trouble adjusting to sleeping during the day and working at night, and this can lead to insomnia.

Delayed sleep phase syndrome: This disorder affects the timing of sleep. People with DSPS tend to fall asleep very late at night and have difficulty waking in time for work, school or other appointments.

Advanced sleep phase syndrome: With this disorder, a person goes to sleep earlier and wakes earlier than desired.

Non-24-hour sleep-wake disorder: With this disorder, a person has a normal sleep pattern, but they live in a 25-hour day. Over time, their sleep cycle is affected by inconsistent insomnia that occurs at different times each night. They may fall asleep at a later time and wake up later, or fall asleep earlier and then wake up earlier.

How are sleep disorders treated?

Treatment options vary depending on the type of sleep disorder involved. One of the first steps is ruling out side effects from any medications, as well as any underlying medical conditions. Having the patient keep a sleep diary for one or two weeks is also important. Often, a combination of behavior therapy, light therapy and possibly medication is involved in providing successful treatment.

Behavior therapy: This usually involves having the patient maintain regular sleep/wake times and avoid naps. This will help "train" the body to the proper sleep time. Engaging in regular exercise is also key as it will encourage physical tiredness. Patients are also advised to avoid caffeine, nicotine and other stimulants, as well as any intense exercise within several hours of bedtime.

Those suffering from delayed sleep phase syndrome should minimize exposure to light during the evening and at night by reducing illumination in their home, and by avoiding the bright screens of televisions and computers. For those suffering from advanced sleep phase syndrome, the situation is the reverse, with light exposure needing to be increased in the evenings. Typically, patients are advised to keep lights on indoors for a longer period, or to spend more time outside in the longer daylight months.

Medication: Medications such as melatonin, or short-term sleep aids, may also be used to adjust and maintain the short-term sleep cycle in order to shift it toward the desired schedule. Melatonin is available over the counter and is a hormone that is found naturally in the body. It promotes sleep and can help with short-term sleep issues. The proper timing of melatonin use varies depending on the condition being treated.

Chronotherapy: A behavioral technique in which the doctor works with the patient to gradually and systematically adjust bedtime until the patient is on the desired schedule. This can take one to two weeks to achieve.

Bright light therapy: Sleep therapists use bright light therapy to help reset a body's circadian clock. The patient is exposed to a high-intensity light (10,000 lux) and the amount of exposure is typically for 30 minutes upon awakening.

We often joke about not getting enough sleep, but for those suffering from true sleep disorders, this is no laughing matter. A good rest, and being able to sleep and wake on a regular schedule, are keys to our being able to function successfully in the world. Lack of sleep, or lack of a regular sleep pattern, can lead to depression, substance abuse and other mental health issues. If you are suffering from a sleep disorder, do not self-treat. Consult with your physician. Treatment is available.

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Parent's goals for their children determine ADHD treatment

A study shows that parents who are interested in the academic success of their child are more likely to start their child on medication whereas parents who are interested in behavior modification are more likely to start behavior therapy.

Parents' goals and concerns for their children with attention-deficit/hyperactivity disorder may influence their decision to start behavior therapy or medication, according to a new study that researchers say supports a shared decision-making approach to ADHD treatment.

Researchers found parents who were focused on their child's academic achievement were twice as likely to have the child started on medications, which include Adderall and Ritalin, as other parents.

Parents who expressed goals of improved behavior and interpersonal relationships were 60 percent more likely to start behavior therapy - which involves parents meeting with a counselor to learn how to manage a child's behavior.

"Studies like this really suggest that taking a shared decision-making approach may be one way to match the kids for whom (treatment) is warranted to the best treatment," Dr. Alexander Fiks, from The Children's Hospital of Pennsylvania in Philadelphia, said.

"For parents, the real thing is to ask pediatricians to really explain the pluses and minuses of all of the different options, and to make sure they can articulate what they're really most hoping to achieve," Fiks, the study's lead author, told Reuters Health.

According to 2011 guidelines from the American Academy of Pediatrics, "family preference is essential in determining the treatment plan" for children diagnosed with ADHD.

But Fiks said no one had looked at whether there were benefits to assessing parents' preferences and goals for treatment.

"There are barriers in real-world settings," he noted. "It takes time, people are busy."

For their study, Fiks and his colleagues surveyed the parents and guardians of 148 children with ADHD, ages six to 12, about their goals for treatment and the acceptability, feasibility and side effects they associated with different treatment options.

None of the children were using a combination of behavior therapy and medication at the outset, although some were using one or the other.

Six months later, 46 of the 108 children not initially using medication had started on the drugs and 30 out of 124 had started behavior therapy, according to findings published in Pediatrics.

Not surprisingly, researchers said, parents who had initially agreed with statements such as, "Medication is a reasonable way to help my child" and, "I would have trust in my doctor to treat my child's ADHD with medicine" were more likely to go that route.

Likewise, children whose parents rated behavior therapy as more acceptable and said they would be comfortable working with a counselor were more likely to be receiving therapy six months later.

What was newer and more surprising, Fiks said, was how closely treatment goals aligned with which families opted for medication and which started behavior therapy.

Dr. Laurel Leslie, who has studied treatment of ADHD at the Tufts University School of Medicine in Boston, said those goals and subsequent choices are consistent with scientific evidence.

"What we do know is, a lot of the medications last under eight hours. So if you're taking a medication, it's probably only working during school time," Leslie, who wasn't involved in the new study, told Reuters Health.

Behavior therapy, on the other hand, is going to have the strongest effects with the family, at night and on weekends, she said.

According to the Centers for Disease Control and Prevention, parent reports suggest close to one in 10 kids and teens in the U.S. has ever been diagnosed with ADHD, and two-thirds of those with a current diagnosis are taking medication.

"I think this particular study speaks to the need to spend a little bit more time getting to know families … their own hopes and wishes for what is going to improve and preferences for how to go about making those benefits happen," said Dr. Alice Charach, the head of neuropsychiatry at The Hospital for Sick Children in Toronto.

Charach, who also wasn't involved in the new research, recommended parents collect ideas and information before meeting with their child's pediatrician.

"It's helpful to have thought about what you hope to get out of the appointment and what your goals are for the child," she told Reuters Health.

By the time children get to be nine or 10 years old, Charach added, they should be involved in the shared decision-making process as well.

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