Bose Ravenel, M.D., an emeritus member of the Physicians Resource Council at Focus on the Family and a practicing pediatrician for many years, explains a program that he is successfully using in his private practice:
David Stein, Ph.D., the author of Unraveling the ADD/ADHD Fiasco: Successful Parenting Without Drugs, has described a novel behavioral approach to managing ADHD behaviors and reported encouraging data on [the] effectiveness of using this approach, without relying on stimulant medication.
For those parents who might prefer to approach dealing with their child's ADHD behaviors without medication, Dr.
Stein provides a conceptualization of ADHD and an approach that has been successful for some families. His Caregivers Skills Program (CSP) is based upon assumptions that depart from those upon which conventional behavioral management is based. These assume that ADHD children can be enabled and trained to develop those behavioral traits they lack, and that effective behavioral management relies upon avoiding material reinforcements, incentives, or token economy programs.
However, for CSP, no rules are posted, and contingency responses to target behaviors are imposed upon the slightest sign of inappropriate behavior. Accountability for appropriate behavior is transferred to the child. Reinforcement for appropriate behavior is stressed, consisting of social reinforcement only. The approach is considered strict, but not punitive.
The program depends entirely upon parental management of the target behaviors in the home environment and only involves the school in the small minority of cases where gains in the home environment do not generalize to the school. Stein's research has found that gains are realized whether behavioral problems are encountered primarily in the home or in school.
Stein found that 11 of 12 targeted ADHD behaviors improved dramatically or disappeared within four weeks among the 37 children fulfilling DSM-IV criteria for ADHD ages 5 to 11 years included in the study. These gains were stable at follow-up one year after treatment.
In 81 percent of children, gains generalized to the school setting, and in the remaining 19 percent institution of a school component (daily report program) extended the behavioral improvement into the school setting.
Although the study is uncontrolled, the results appear to justify further clinical trials with control groups receiving alternative methods of management, considering the lack of evidence for long-term effectiveness of the prevailing medication centered approach and the virtual absence of risk.
Dr. Ravenel goes on to say:
The CSP approach is completely free of risk in contrast to the prevailing medication based approach. I have witnessed a number of cases of effective resolution of ADHD behaviors with the CSP approach in my general pediatric practice. I recognize that Stein's data are uncontrolled, and my case management success anecdotal, but the absence of risk of adverse effects suggests that trials of this revolutionary behavioral approach at least be done comparing results with conventional stimulant medication management.
Nevertheless, there are potential problems with CSP that mean it may not be for everyone. Dr. Ravenel says, "I recognize that some parents will likely be unable or unwilling to devote the consistency of effort required for successful implementation of the CSP approach. Therefore, stimulant medication management will likely retain a place in management. Nevertheless, prudence suggests that its use be restricted to children or adolescents whose behaviors are more problematic and in circumstances where caretakers cannot or will not utilize the CSP approach successfully."
One of my favorite ADHD experts and researchers, Dr. Russell Barkley, at the University of Massachusetts Medical Center, seems to agree with Dr. Ravenel about the use of behavioral therapies in ADHD kids when he writes in the online version of Scientific American:
Treatment for ADHD should include training parents and teachers in specific and more effective methods for managing the behavioral problems of children with the disorder. Such methods involve making the consequences of a child's actions more frequent and immediate and increasing the external use of prompts and cues about rules and time intervals.
Parents and teachers must aid children with ADHD by anticipating events for them, breaking future tasks down into smaller and more immediate steps, and using artificial immediate rewards. All these steps serve to externalize time, rules, and consequences as a replacement for the weak internal forms of information, rules and motivation of children with ADHD.
Although Dr. Stein and his CSP method actually advocate avoiding prompts and reminders and stimulants, Dr.
Barkiey feels strongly that behavioral approaches should be used "in addition to stimulant medications - and perhaps antidepressants, for some children.'' Therefore, let's take a look at medications for ADHD.
Prescription Medications
Many, many parents call or write Focus on the Family to ask about using prescription medications for ADHD. They've heard the controversies and they are worried that starting a medication might be bad. On the other hand, many worry that not starting a medication may be harmful. They ask, "What should we do?"
Without a doubt, the use of prescription drugs for both children and adults is one of the most successful short-term therapies available. There is a virtual mountain of evidence supporting the safety and effectiveness of using medications in ADHD, although these are all fairly short-term studies, with none going more than two years.
According to these studies, anywhere from as few as 70 percent to as many as 95 percent of ADHD patients benefit from appropriate medication. These medications seem to dramatically reduce disruptive behavior, improve school performance, and even raise IQ test scores. The medications seem to work equally with boys and girls.
No one knows exactly how they work, but they probably affect the electrochemical processes in the brain, which regulate behavior. As noted above, they are not cure-alls, and, as below, they can have significant side effects. Further, they do not improve the ability to memorize and may not help language processing. In addition, they do not help social skills.
Next post, we'll talk more about prescription Stimulant Medications. If you need more information fast, I strongly suggest you can get How To Take Care Of Adhd Child right away!
