Drugs Vs. Psychotherapy Vs. Combonation

First, Almost ALL agencies indicate counseling should be tried first.

"For most of the disorders reviewed... there are psychosocial treatments that are solidly grounded in empirical support as stand-alone treatments. The preponderance of available evidence indicates that
psychosocial treatments are safer than psychoactive medications. Therefore the working group recommends that in most cases psychosocial interventions be considered first," the report says.
The report, Psychopharmacological, Psychosocial, and Combined Interventions for Childhood Disorders: Evidence Base, Contextual Factors, and Future Directions, is available at
<http://www.apa.org/pi/cyf/childmeds.pdf>.  www.apa.org/pi/cyf/childmeds.pdf

And IF YOUR CONSIDERING drugging a child, read what the studies say about effectiveness!

The following article was published in a Best Practices journal in the spring of 2000.  The Nurtured Heart Approach, Howard N. Glasser, Executive Director, The Children's Success Foundation

The Nurtured Heart Approach has been practiced at Tucson's Center for the Difficult Child (CDC) between 1994 and 2001. It is a strategic family systems approach designed to turn the challenging child around to a new pattern of success. The approach has also been found to produce substantial success in helping the average child flourish at higher-than-expected levels of functioning.The approach is now used in thousands of classrooms nationally, and its strategies have been adopted with substantial success as the school-wide discipline plan in several Tucson schools.

The Nurtured Heart Approach teaches significant adults how to strongly energize the child's experiences of success while not accidentally energizing his or her experiences of failure. Most approaches, because they were designed for the average child, get stretched beyond their capacity when applied to challenging children. Traditional approaches for parenting and teaching can easily backfire with challenging children: they inadvertently reward children by providing more energy, involvement and animation when things are going wrong. Challenging children wind up being very confused because they perceive a high level of incentive for pushing the limits and for negative behaviors and little incentive to make successful choices. Often, the harder adults try applying these normal methods, the worse the situation becomes, despite the best of intentions.

Since The Nurtured Heart Approach was first introduced at CDC in 1994, a number of studies have been undertaken and several positive outcomes have emerged.

School Outcomes: Tolson Elementary School in Tucson Arizona, a Title I school of over 500 children (80% free or reduced lunch) has shown remarkable progress since beginning a school-wide Nurtured heart Approach intervention in 1999. Prior to that many children were referred for ADHD assessments and were put on medications. They had eight times the normal number of school suspensions per year as other schools in the district and teacher attrition was well over 50% per year. Since that time there has only been one child suspended, no children at all diagnosed as ADHD and no new children on medications. Teacher attrition has dropped to less than 5% and special education utilization has dropped from 15% to 5%. Best of all, the school has gone from the worst in district as measured by standardized test scores to having dramatic and continuing positive progress. This data is in keeping with other informal observations noted when this approach has been applied in other school-wide applications.

Many HeadStart programs around the county use The Nurtured Heart Approach. The city of Tucson adopted the approach in the year 1999 and has used it successfully every since. The data they have collected for the 3,000 underprivileged children they serve each year confirms that in this time period they too have not needed to send a child for a diagnostic assessment or medication services at all. They use the approach class-wide and in addition to feeling that the approach helps all the children to flourish it has helped them to help the at-risk children to do well within the classroom setting without needing outside services.

Both Tolson Elementary and Tucson HeadStart report a strong increase in their ability to positively impact the parent communities they serve.

Recidivism:

Published findings from the 1999 "Year in Review" study conducted by Pima County Juvenile Court in relation to the Pre-Adolescent Diversion Project (PADP) of Tucson's Child and Family Resources. The project's parenting component and several other aspects of the program are based on The Nurtured Heart Approach. The project is a 16-hour workshop series over 4 weeks for first offending youth and their families.

According to Pima County Juvenile Court researchers, first offenders referred to other Juvenile Court programs have shown a 32% rate of recidivism, whereas the rate of re-offense for those youth who have completed PADP with their families is only 18%. This represents a 45% rate of improvement over other diversionary programs. Typically, youth who re-offend do so at escalating rates of intensity, committing bigger crimes and more often. The graduates of PADP who did re-offend committed lesser offenses. The statistical significance of the 18% rate of recidivism is .00001. This occurrence could not have happened by chance alone. Therefore, the strategies and approach of the Pre-Adolescent Diversion Project have been shown to produce noticeable improvement.

Medications:

Another indicator of The Nurtured Heart Approach's effectiveness may be related to informal research regarding the use of medications among CDC clients.

Although many children referred to CDC are already on medication, CDC has scrutinized the records of children who are referred to the agency with no prior evaluation and therefore are not taking medications at the time of intake.

Upon close examination of the initial assessments of those already on medications and those not on medications, no difference is discernible. Those who are referred who are not on medications typically have very much the same symptoms and levels of severity as those who are already on medications at the time of intake. Most frequently those symptoms match the profiles of Attention Deficit/Hyperactivity Disorder (ADHD) and Oppositional-Defiant Disorder, with problems of aggression, compliance, impulsivity, distractibility, and a preponderance of school related issues.

National statistics show that of all children going to a primary care physician or a child psychiatrist for an initial assessment with these kinds of symptoms, 75% are prescribed medications at the time of that evaluation. It can therefore be assumed, given the kinds of symptoms and the level of severity of the children referred to CDC, that approximately 75% of these children would be put on medications if CDC's very first step were referral to a physician for an evaluation.

During a 10-month period in 1998, CDC worked with 211 children. Of these, 51 were already on medications prior to referral to CDC. Of the 160 children who were not already on medications, only eight were subsequently referred for psychiatric evaluations and only four were actually prescribed medications subsequent to the evaluation. This represents less than a 3% rate of utilization of medications. Perhaps just as interesting is that nine of the 51 on medications were successfully transitioned off medications during this time frame.

Overall improvements:

A separate on-going study conducted collaboratively by the Community Partnership for Southern Arizona (CPSA) research department since late 1996 involves pre- and post-treatment administration of the Connor's Parent Rating Scale with all CDC clients. Preliminary assessment of the data indicates excellent results in terms of efficacy of treatment. All scales of the Connors show improvement at the .01 level of significance and five of the six scales show improvements beyond four standard deviations. The study further confirms that, in general, the presenting symptoms of CDC clients at intake show a high degree of severity while the outcomes show children well within the mid-range of normative behaviors. Further analysis will be forthcoming.

Utilization of high-level services: Considering the consistently high severity of CDC clients at intake, a fairly remarkable outcome has emerged over the years in relation to the number of CDC children who eventually needed high level and costly interventions such as out-of-home placements. Since 1994, only 8 children have required higher levels of intervention. This is despite the fact that many of the children referred to CDC over the years had one or more mental health related hospitalizations prior to referral to CDC.

The Nurtured Heart Approach also has been called upon numerous times to help transition children from high-level interventions to normal family life and regular levels of treatment. The related preventive request--to take on a child headed for a high-level intervention as a way of re-stabilizing the child--is also a routine facet of the capacities of this approach.

Re-utilization:  In a study of 808 of CDC cases from November 1994 through October 1998, only 28 children needed to have their cases re-opened and, in most of these instances, subsequent treatment was very brief and successful. Most of these families needed only a little inspiration or clarification on how to get back on track with the approach. The rate of re-utilization is less than 3.5%.

Cost/efficacy:  Many consumers do not qualify for the public mental health system and find the cost of on-going private treatment prohibitive. The Nurtured Heart Approach, typically taught for 8-12 total hours over a four-week period, is very well-suited to multi-family group scenarios, thus allowing families without insurance benefits to have an alternative form of affordable treatment.

In 1996, Dr. Shirli Ward researched The Nurtured Heart Approach for her doctoral dissertation. Comparison of a Nurtured Heart Approach large group format (over 30 parents in one group training) showed levels of success similar to that produced by therapeutic work with individual families. Dr. Ward pointed out that other prominent parent training programs were limited in size to a maximum of eight families, making The Nurtured Heart Approach considerably more time and cost effective.

The study also found that it was not necessary for both parents to participate in the training to achieve beneficial results. In one component of the study, only mothers were involved in the training and their children were not directly involved in the treatment. The mothers were able to become, in effect, the "therapists." The results reflected a high degree of satisfaction with the program in terms of improvements in family life and the progress their children made.

Dr. Ward further assessed the effect of the approach on child and parent functioning using the Devereaux Scale of Mental Disorders along with the Parent Stress Index, the Parenting Sense of Competence Scale, the Beck Depression Inventory, and the Forehand Satisfaction Survey.

Dr. Ward found that, relative to subjects in the comparison group, those involved in The Nurtured Heart Approach parent-training model demonstrated significant changes in functioning following treatment. Mothers reported significant (.01) improvements in their child's behavior related to the following: conduct, anxiety, communication, acute problems, and overall severity. In addition, in terms of their own well-being, mothers reported fewer depressive symptoms, decreased stress levels and increased parenting effectiveness and satisfaction following treatment.

These results were found to be consistent across the researched diagnostic categories of Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, Conduct Disorder and Depressive Disorder as well as for children for whom treatment was sought for general noncompliance and Adjustment Disorder.

In 1994, Dr. Lorence Miller, also using the Devereaux Scale of Mental Disorders, found that a sample population of children in treatment at CDC had higher levels of severity at entry into treatment than the comparison groups of selected specific diagnoses used in the Devereaux groups own studies of criterion-related validity. The CDC sample population had more severe problems in all areas but attention. Dr. Miller's post-test results for both The Nurtured Heart Approach family treatment and large multi-family group treatment modalities were shown to have extremely significant effects toward normalized behaviors.

http://www.sciencedaily.com/releases/2009/06/090629165611.htm
Placebo Effects In Caregivers May Change Behavior Of Children With ADHD

ScienceDaily (June 30, 2009) — Stimulant medications, such as Ritalin and Adderall, are the accepted treatment to stem hyperactivity in children with attention deficit-hyperactive disorder (ADHD) and
improve their behavior.

Now a recent review of research by University at Buffalo pediatric psychologists suggests that such medication, or the assumption of medication, may produce a placebo effect -- not in the children, but
in their teachers, parents or other adults who evaluate them.

A placebo effect is a positive change in symptoms or behavior after a patient receives a "fake" medication or procedure; in other words, the belief can become the medicine. In this case, the review suggested
that when caregivers believed their ADHD patients were receiving ADHD medication, they tended to view those children more favorably and treat them more positively, whether or not medication was actually
involved.

"The act of administering medication, or thinking a child has received medication, may induce positive expectancies in parents and teachers about the effects of that medication, which may, in turn, influence
how parents and teachers evaluate and behave toward children with ADHD," said UB researcher Daniel A. Waschbusch, Ph.D., lead author of the review.

"We speculate that the perception that a child is receiving ADHD medication may bring about a shift in attitude in a teacher or caregiver. They may have a more positive view of the child, which
could create a better relationship. They may praise the child more, which may induce better behavior."

Such a placebo effect in caregivers could have both good and not-so-good results, Waschbusch added. "If teachers treat children more positively if they think they are on medication, that is a good thing. But if the child's medication is increased because caregiversthink it is effective, that may not be a good thing."

Waschbusch is an associate professor of psychology in the Department of Pediatrics at UB and conducts his research in UB's Center for Children and Families. The study was published in a recent issue of
the Journal of Development & Behavioral Pediatrics.

Waschbusch and colleagues reviewed existing studies that evaluated whether placebos produce significant changes in children with ADHD and assessed four possible ways placebos could have an effect:

    * Through the child's expectations of a change -- The analysis showed that any change in children's behavior was a direct result of the medication, not the expectation.
    * By producing changes in how caregivers perceive children with ADHD when they think they are on medication -- The researchers determined the studies suggested that this may be a viable mechanism
for the placebo effect.
    * By producing changes in how caregivers behave toward children with ADHD who they think are on medication, which in turn, could produce changes in the child -- The analysis supported this hypothesis.
    * Placebos may operate through classical conditioning. "For example," explained Waschbusch, "if a parent routinely gives their child active medication in pill form and then sees their child's behavior immediately improve, they will likely learn to connect administering a pill with improved child behavior. This learned connection could then be generalized to administering a placebo pill."

Waschbusch said the next step in this investigation could be a study that observes parents and children interacting under three different conditions: after children received a pill with real medication, after
children received a pill with fake medication (a placebo) and after children didn't receive any pill.

"Comparing these conditions would provide information about the effects of actual medication relative to just getting a placebo," he said. William E. Pelham, Jr., Ph.D., and James Waxmonsky, M.D., from UB,  and Charlotte Johnston, Ph.D., from the University of British Columbia, are co-authors on the study.

MTA STUDY

The Ethics and Science of Medicating Children[1], Jacqueline A. Sparks, Ph.D.[2],

Center for Family Services, Palm Beach County, Florida, and Barry L. Duncan, Psy.D.,  

Institute for the Study of Therapeutic Change, Ft. Lauderdale, Florida.

"...Attention Deficit Hyperactivity Disorder (ADHD) is arguably the most controversial topic in recent mental health history because: the ADHD diagnosis is not defined by a biological marker (Leo & Cohen, 2003) is quite subjective, and is not easily distinguished from the everyday behavior of children (i.e., the diagnosis lacks reliability and validity [Duncan, Miller, & Sparks, in press]); despite the guidelines of diagnostic prevalence of 3-5% established by the 1998 NIH consensus panel, diagnostic rates are as high as an astounding 33% in some locations (Lefever, Arcona, & Antonuncio, 2003); despite the lack of evidence for long term safety and effectiveness, stimulant medication treatment for ADHD has increased an astronomic 700% in the 90’s (Mackey & Kipras, 2001).

Without consideration of design flaws, stimulants, primarily Ritalin, have unequivocally established their efficacy over placebo in small, short term randomized clinical trials on narrowly defined ADHD symptoms (not on social or academic measures). To address the criticism that short term efficacy studies do not address the more important issue of effectiveness—or the success of stimulants on a wider range of outcome measures in real settings over a longer period of time—the Multimodal Treatment Study of Children with ADHD (MTA) (Cooperative MTA Group, 1999) was conducted. It compared four treatments for ADHD: behavioral treatment (BT), medication management (MM), combined BT and MM, and a community comparison treatment control group. The MTA has already being touted, in both popular and professional publications, as proving that stimulants are more effective than behavioral intervention. Similar to the Emslie studies, given the impact of the study on prescription practices, it is important to scratch a little below the surface to understand its conclusions. 

First, on the positive side, the most unique element of the study is its large sample. Previous studies of ADHD treatment have generally been small, with 1 to 20 subjects in each condition. With 144 subjects in each group, the MTA was far superior in numbers alone. The MTA also surpassed its predecessors because it evaluated treatment for 14 months instead of the customary 12-16 weeks. Another impressive aspect is the comprehensive nature of the assessments conducted. Rather than the simple clinician rated outcome measures that characterize most studies, the MTA selected a total of 19 measures from multiple sources (parents, teachers, child, peers, and objective tests and observations) in multiple domains of functioning (ADHD symptoms, peer and parent-child relationships, classroom behavior, and academic achievement).

      Before looking at the specific problems with the MTA, consider the results collected at the 14-month endpoint, as summarized by Pelham (1999), one of the principle investigators:

·                     all 4 groups showed dramatic improvement;

·                     MM was superior to BT on parent and teacher ratings of inattention and teacher ratings of hyperactivity, but not on any of the other 16 measures[i];

·                     combined treatment and MM did not differ on any dependent measure; combined treatment was better than BT on parent and teacher ratings of inattention and parent ratings of hyperactivity and oppositional behavior, and reading achievement;

·                     both MM and combined treatments were superior to community treatments on parent and teacher symptom ratings and teacher-rated social skills, while BT was equivalent to community treatments; the 2 conditions with BT were superior to community treatment on parent-child relationships (p. 982).

     Let’s examine these results in light of the usual design flaws of drug studies. First, as Breggin (2000) articulates,  the study was not placebo controlled or double blinded. The MTA not only lacked a pill placebo control group, but also relied only on evaluations made by teachers and parents who were not blinded to the treatment conditions.

Emphasis to this criticism, Breggin suggests, is added by the fact that the only double blind measure (blinded classroom raters) found no difference among any of the treatment groups.

Next, consider the issue of client v. other ratings. Neither the subjects themselves (the 7-9 year old children) nor their peers rated the children as more improved when using medication than when using behavioral or community alternatives. Breggin suggests that the negative findings from the blinded classroom observers, the children themselves, and their peers indicate that stimulant drugs offer no advantages over non medication alternatives (2000).
     Finally, recall that the time of measurement is a crucial factor to consider. Here is the kicker of this study: Assessment occurred at the 14 month endpoint while subjects were actively medicated, but after the fading of therapy. Endpoint measures were taken 4 to 6 months after the last, face-to-face, therapeutic contact! Thus, the endpoint MTA treatment comparison was for active MM treatment versus withdrawn BT.

The study’s slightly drug favoring results were a foregone conclusion based on the very way it was designed (Pelham, 1999).

Given that the results reflect medication v. withdrawn therapy, the lack of difference on 16 of 19 measures (when MM was compared with BT) and on 19 of 19 measures (when community treatment of mostly medicated children was compared with BT) is even more telling.

Also impressive, given the withdrawal, is that 75% of the children in the BT condition were maintained without medication for 14 months, including one-half of those who were medicated at study entry (Pelham, 1999).

Two papers addressing the 24 month follow-up data are under review (Pelham, personal communication). They show that the group differences are even smaller because the MM and combined groups have lost much of their effect, while the BT and community groups have retained their gains.

Further, at 24 months, the majority of parents in the BT group thought their kids were doing well enough that they did not medicate them even after the study had ended (Pelham, personal communication).

Moreover, the MTA reported that parents significantly preferred the behavioral and combined treatments over medication alone. Even when a preference for medication exists, most parents desire not to medicate their children for the long term as evidenced by the fact that most ADHD individuals stop taking stimulant medication during late childhood or adolescence (Pelham, 1999). This makes non medical intervention particularly important in light of the effects of stimulant medication, though beneficial in the short term, do not last beyond medication termination. This is of course why the endpoint measure in the MTA was of active medication and withdrawn BT and not vice versa.

Perhaps parental concern about long term stimulant use is most fueled by adverse drug reactions (ADR). In the MTA, a whopping 64% of the children were reported to have some ADRs; 11% were rated as moderate, and 3% as severe, with this category representing largely “depression, worrying, and irritability.”

In his review of the stimulant medication research, Breggin (1998) reports that these troubling reactions to stimulant medications are common across clinical trials.

Finally, emphasizing the importance of parental preference, consider the recent revelation made by one of the principle investigators of the MTA, psychiatrist Peter Jensen. Jensen has been traveling the globe extolling the virtues of stimulants over behavioral interventions. To an audience at a recent APA meeting, Jensen shared that his son is diagnosed with ADHD, and that he and Mrs. Jensen opted for behavioral treatment instead of medication (O’Connor, 2001). Hmmm… 

The MTA, as well as all the available evidence regarding stimulants, says nothing that indicates that medication should be privileged over any other option, especially as guided by client preferences. Moreover, and more troubling, the overuse of stimulants is a stop gap measure that locates the problem exclusively in the child (LeFever et al., 2003) and creates an “attention deficit” in professionals to responding more creatively to behaviorally demanding children and the less than perfect learning contexts to which they are expected to adapt. Mental health professionals need to challenge business as usual and encourage a broader discussion of the socioeconomic and cultural issues affecting children and their success in the schools.

On balance, given the less than overwhelming empirical support and apparent medical risks, as well as the nebulousness of the ADHD diagnosis itself (Leo, 2000), the judicious use of stimulants seems warranted. LeFever et al (2003) make the following (edited) recommendations:

1.    Before any treatment, a suspected case of ADHD requires a thorough evaluation that establishes that the symptoms cannot be better explained by other factors, and are inconsistent with developmental level.

2.    If a child receives a diagnosis of ADHD during the preschool years, stimulants should be avoided because many are resolved by the first or second grade.

3.    Behavioral interventions ought to be tried first because of their comparable efficacy and lower medical risks than drug treatment.

4.    If the child has not responded adequately after 6 months of therapy, then drug treatment may be considered.

5.    Psychotropic medications should not be combined until there are existing data from controlled studies supporting the safety and efficacy of the combination in children (p. 12).

Follow Up Later:

ADHD drugs: They work only for the first 3 years, 15 November 2007
ADHD (attention deficit hyperactivity disorder) drugs such as Ritalin work only for the first three years. Despite this, they are often prescribed throughout childhood and well into adolescence. After those first three years, ADHD can be just as successfully treated with behavioural therapy. The Multimodel Treatment Study has been monitoring the health of 600 young people with ADHD since the early 1990s.
In addition to discovering the short-term benefits of drugs such as  Ritalin and Concerta, the study has discovered that the drugs could also stunt children’s growth. Ironically, it was the initial findings of the same study that sparked much of the growth in ADHD drug sales. In 1999, the study concluded  that the drugs worked better than therapy over the first year. Prof William Pelham, one of the study’s co-authors, said: “I think that we exaggerated the beneficial impact of medication in the first study.  We had thought that children medicated longer would have better outcomes. That didn’t happen to be the case.”
(Source: BBC Panorama, November 12, 2007).