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When children are diagnosed with Attention Deficit Hyperactivity Disorder, stimulant medications like Ritalin are usually the first line of treatment.

Doctors recently issued new guidelines that mostly uphold the role of those medications, but many experts argue that other effective behavioral treatment methods are being ignored.

When 6-year-old Brody Knapp of Kansas City, Missouri, was diagnosed with ADHD last year, his father, Brett, was skeptical. He didn’t want his son taking pills

“You hear of losing your child’s personality, and they become a shell of themselves, and they’re not that sparking little kid that you love,” Brett says. “I didn’t want to lose that with Brody, ’cause he’s an amazing kid.”

Brody’s mother, Ashley, had other ideas. She’s a school principal and has ADHD herself.

“I was all for stimulants at the very, very beginning just because I know what they can do to help a neurological issue such as ADHD,” Ashley says.

More and more families have been facing the same dilemma. The incidence of ADHD has shot up in the last two decades, and now almost 1 in 10 children in the U.S. is diagnosed with it.

The new clinical guidelines issued last week by the American Academy of Pediatrics recommend that when kids are diagnosed with ADHD, they also get screened for other mental illnesses.

The treatment recommendations, however, remain mostly the same as previous guidelines. They advise that anyone 6 or older should start taking medication and get behavioral therapy as soon as they are diagnosed. Children 5 and younger are advised to start with behavioral treatment first

Some experts are disappointed that the new rules don’t call for starting with therapy first for kids over age 5, too.

“I think it’s a huge disservice to not just the children that we’re trying to treat but also to the parent who would prefer to have behavioral interventions,” says Erika Coles, a psychologist and clinical director of the Center for Children and Families at Florida International University. Her work examines behavioral treatments like parent training and school support.

A 2016 study found that giving kids, parents and teachers an eight-week course in behavioral techniques before starting medications led to fewer symptoms. 

Another study by Coles and other researchers published this summer found that a similar program of interventions actually reduced the amount of medication needed by many kids with ADHD. 

And 37% of kids getting that training didn’t need medications at all. 

“So we really need to think about a more global treatment perspective when it comes to treating kids with ADHD, and behavioral treatments do a much better job of addressing the domains of impairment that kids with ADHD experience,” Coles says.

Fewer meds also means fewer side effects. Some kids have trouble sleeping, lose their appetite, see decreased growth or experience personality changes, and there’s not much research on what it means to stay on these drugs for years.

A member of the subcommittee that wrote the new guidelines says they reviewed the research on behavioral treatment first, but the evidence for it was not strong enough to change the guidelines.

But both the American Academy of Pediatrics, its critics and other ADHD experts agree on one major point: not nearly enough kids are getting the therapy they should.

“It’s certainly true that when you watch TV, you’re not going to see a lot of commercials about behavioral treatments, but you very well may see some new ones about medication,” says Carla Allan, a psychologist at Children’s Mercy Hospital who treats Brody Knapp.

Only about 60% of kids in the U.S. with ADHD have ever had any behavioral treatment outside of school. That compares with about 90% of kids who get medication, according to a 2018 study.

Andrea Chronis-Toscano, the director of the Maryland ADHD program at the University of Maryland and a coauthor of the study, says there is a lack of qualified experts, but health coverage also plays a role.

Uninsured kids are least likely to get any ADHD treatment, but among kids who do have healthcare coverage, those with private insurance actually get behavioral treatment less often than kids on Medicaid. 

“One of our studies showed that children on public assistance actually had greater access to some of our psychosocial treatments,” Chronis-Tuscano says.

Chronis-Tuscano thinks that may help explain another surprising finding: Children from wealthier families get behavioral help less often than many lower income families, even though kids from wealthier families get medication more often.

A recent study by researchers at Boston University found the same thing.

Chronis-Tuscano admits it’s unclear exactly why this is, but she suspects it may have to do with poor mental health care coverage by many private insurers.

Attitudes about treatment may play a role as well. Some groups, such as Latinos, are often skeptical about prescription medications and tend to avoid using them.

Ultimately, Chronis-Tuscano thinks one of the biggest challenges for ADHD experts may be simply cutting through the noise of drug ads and online misinformation about the condition.

“What we need to do is get our message beyond the scientific community to parents and teachers and pediatricians about the importance of making sure that children with ADHD are always getting behavioral therapy either alongside their medication or even prior to their medication,” Chronis-Tuscano says.

But even when families do opt for behavioral treatment, it can be a lot more work than just popping a pill. And it can be especially hard when the parents themselves, like Ashley Knapp, have ADHD, a condition that can run in families.

Ashley and Brett decided to start their son Brody out with behavioral treatment first. Ashley still uses techniques she learned to keep Brody on track with his chores. 

She admits that took some getting used to. She says it feels like micromanaging.

“I don’t like the idea that I have to tell my kids or anybody what to do. I want them to be able to think for themselves and make those safe choices, but at this point, that’s just not possible yet for Brody,” Ashley says.

They’re in a good place now, but they did decide to give Brody medication after a few months of behavioral treatment, after Brody had a violent outburst. He now takes Concerta.

His dad, Brett, says he’s okay with his son taking pills now. Because doing those months of therapy first gave him a much better understanding of Brody’s condition. 

“It’s not necessarily for the child,” Brett says. “It really is for the parent to realize what an ADHD kid looks like. And for the perspective, I think it helped out greatly to kind of realize how I need to interact and how I need to talk and how I need to work with my child.”

Alex Smith is a health reporter for KCUR. You can reach him by email at alexs@kcur.org

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