Consider how research support for ADHD treatments are typically established. The ‘gold-standard’ approach would be a randomized-controlled trial in which children with ADHD are randomly assigned to the treatment or control group. The treatment being tested would be carefully and consistently implemented . If possible, children in the control condition would receive a placebo treatment so that nobody is aware of which participants were treated and which were not. Measures collected before and after treatment would enable the researchers to determine whether the treatment yielded significant benefits relative to the placebo.If this were found, empirical support for the treatment would have been obtained. And, if these findings were replicated in a second study, one could be confident that the treatment yields positive effects for children with ADHD.
While this approach is valuable for establishing scientific support for any treatment, it is not without shortcomings as a guide for parents seeking treatment for their child. There are several reasons for this.
First, although the research-supported treatment may be available in the community, it may not be implemented in the same way as in the research studies and thus be less effective than what research suggests. For example, the rigor with which medication treatment is initiated and monitored in community settings is often quite different from what occurs in clinical trials.
Second, the outcomes collected in research studies may be narrower than what parents care most about. For example, while documenting that a treatment reduces core ADHD symptoms is important, parents may care more about how treatment affects their child’s functioning more broadly. Will it help their child do better at school, be more successful socially, and get along better with siblings and parents? Many studies do not consider this broader range of outcomes.
Third, outcomes in clinical trials often do not include long-term follow-up of initial treatment effects, making the duration of benefits uncertain.
How do different treatments really work in the community? – While carefully controlled clinical trials are essential for establishing scientific support for different ADHD treatments, it is also important to examine how parents feel about the treatments they actually select for their child. How parents feel about ADHD treatments they have tried for their child provides an important complement to the published clinical trials data, and can also help guide parents’ treatment choices.
Results from a survey conducted by ADDitude Magazine of nearly 2500 parents provide helpful data on this question. In this survey, parents were asked about how helpful they had found the treatment strategies they were using currently, or had used in the past. Key findings are summarized below and a complete summary is available at www.additudemag.com/adhd-treatment-options-caregivers-adults-survey-results.
How often are different treatments used? – Despite being infrequently recommended by physicians and other clinicians, a wide-range of non-medical treatments were being used by parents.Below are data on 10 different treatment approaches reported by parents in descending order of frequency. The percentages sum to more than 100% because many children were receiving multiple treatments and/or had previously used different treatments.
67% – Prescription medication37% – Exercise36% – Vitamins, minerals, or supplements29% – Diet/nutrition plan26% – ADHD coaching/counseling13% – Mindfulness meditation10% – Behavior therapy/parent-training classes5% – Neurofeedback with a clinician3% – Home-based brain training
It is not surprising that medication treatment, which currently has the strongest research support of any ADHD treatment, was clearly the most common treatment utilized. However, behavior therapy is generally regarded as the other ADHD treatment wth the strongest research support and it was used less often than many treatments that have less supportive research. This may reflect challenges that parents face in accessing this treatment in their community.
How well do parents feel different treatments work? – Below is the percent of parents who reported that each treatment type was either ‘Extremely or Very Effective’.
49% – Exercise41% – Prescription medication33% – ADHD coaching/counseling33% – Behavior management/parent-training classes30% – Neurofeedback with a clinician27% – Mindfulness meditation24% – Diet/nutrition plan24% – Home-based brain training14% – Vitamins, minerals, or supplements
Below is the converse of this data, i.e., the percent of parents who found each treatment ‘Not very effective or Not at all effective’.
5% – Exercise13% – Behavior management/parent-training classes19% – ADHD coaching/counseling19% – Mindfulness meditation26% – Prescription medication27% – Diet/nutrition plan27% – Neurofeedback with a clinician33% – Home-based brain training42% – Vitamins, minerals, supplements
Several aspects of these results are noteworthy.
First, exercise was the ADHD treatment approach most likely to be rated as effective and least likely to be seen as ineffective. What parents perceive about exercise is ahead of the current science, as research on exercise as an ADHD treatment is rather limited; I expect we will begin seeing a number of studies on this topic appearing over the next several years.
Second, although medication is widely regarded as the ADHD treatment with the strongest research support, only a minority of parents felt it was very effective for their child. And, 26% of parents felt it was not effective. This highlights the limitations of even well-researched treatments for ADHD.
Third, no treatment was regarded as very effective by a majority of parents and all treatments were rated as very effective by at least some parents. Thus, while there is is no single approach that is likely to be seen as very effective for the majority of children there are many approaches that parents felt were quite helpful to their child. This suggests although the initial treatment(s) implemented not be sufficiently helpful, other approaches may yield results that parents see as quite beneficial. . Accessing those treatments can be challenging, however, and many treatments are not covered by insurance.
Summary and implications – Results from this survey complement evidence from clinical trials of ADHD treatment by indicating how parents feel about the different treatments they try..While it is discouraging that no treatment was felt to be very effective by most parents, it is encouraging that multiple treatments were reported to work well by some parents. The challenge thus remains finding a treatment approach – or combination of treatments – that is most effective for individual children. That is not easy and is highlighted in this quote from one of the survey participants:
“It is overwhelming at times to try to do all of these treatments,” wrote one caregiver. “I feel parents are on their own… We would have benefited from an interdisciplinary team including pediatrician, therapist and teacher meeting once a year at least and have someone coordinate with us throughout the year to check in.”
Several limitations to this type of study should be noted. First, this is not a nationally representative sample of parents but a convenience sample of parents who chose to complete the survey. The extent to which their experience generalizes to all parents of children with ADHD is not known.
Another challenge is that it is not possible to know the details of the treatments actually provided. A benefit of controlled clinical trials is that the treatment is clearly specified, i.e., you know with confidence what treatment actually entailed. That is not true for a study like this. For example, results indicate that 49% of parents felt exercise was effective for their child. What exercise-based interventions included is unknown, however, and would almost certainly be highly variable across children. The same would be true for any of the treatments that were rated.
A final issue is that parents’ reports about the effectiveness of their child’s treatment may be biased, as parents who devote time and money for a particular treatment may be inclined to view it as effective, even if ‘more objective’ outcome data would not support this. This is why clinical trials go to great lengths to obtain outcome information from individuals who are ‘blind’ as to whether study participants are in a treatment or control group. While this is an important concern, discounting parents’ perceptions of treatment response is problematic given their intimate knowledge of their child. And, because no treatment was rated as very effective by most parents, it is not the case that parents are biased towards seeing anything they try as beneficial. Important to note is that while parents’ perspectives on their child’s treatment is essential, regularly obtaining information from teachers who observe the child at school is also important. A free app from Esteem that I worked on makes it easy to do this and I encourage you to take a look at it. In summary, results from this survey may help inform parents seeking effective ADHD treatment for their child that complements what has been learned from research-based clinical trials. Although current treatment recommendations would focus on stimulant medication and behavior therapy as the ADHD treatments with strongest research support, these findings highlight other options that parents have found to be helpful.In particular, it is evident that no treatment is likely to produce benefits that most parents will be satisfied with. As a result, persistence in finding what works best for one’s child – although challenging – will often be required.
|Copyright © 2020 by David Rabiner|