Fewer than half of children with attention-deficit/hyperactivity disorder (ADHD) were receiving behavior therapy just before the American Academy of Pediatrics (AAP) released clinical practice guidelines in 2011, according to the first national study of behavior therapy, medication, and dietary supplements to treat ADHD in children aged 4 to 17 years.
The findings of the study, which looked at parent-reported data from the Centers for Disease Control and Prevention’s 2009-2010 National Survey of Children with Special Health Care Needs, provide “an important benchmark for clinical practice” because data were gathered shortly before the AAP guideline, the researchers say.
They found that 44% of children had received behavior therapy within the past year; 74% had been treated with medication in the past week; and 10.2% had taken dietary supplements for ADHD in the past year. Overall, 87.3% had received either behavior therapy or medication; 30.7% had received both; and 12.7% had received neither.
Among preschoolers (aged 4 and 5 years), 31.9% had received behavior therapy alone; 25.4% medication alone; 21.2% both therapies; and 21.4% neither.
The AAP guidelines recommend behavior therapy as first-line treatment for preschool children with the addition of short-acting methylphenidate if necessary to further improve ADHD symptoms. For children aged 6 to 17 years, the AAP recommends medication with or without behavior therapy or, preferably, a combination of both types of therapy, especially for elementary-school-aged children.
Medication was the most common treatment, followed by combination therapy and behavior therapy alone. Children with severe ADHD and comorbid conditions were most likely to receive combination therapy. Central nervous system stimulants were the most often prescribed type of medication at 84.8%, followed by the selective norepinephrine reuptake inhibitor atomoxetine, 8.4%.
Children aged 4 and 5 years were least likely to have taken medication. Non-Hispanic white children were more likely to have received medication than children from other racial and ethnic groups. Children aged older than 12 years were less likely than 4- and 5-year-olds to have received behavior therapy in the previous year, as were non-Hispanic white children.
Treatment for ADHD varied significantly by state, with states that had higher medication rates tending to have lower rates of behavior therapy on average and vice versa. The medication rate ranged from 56.6% in California to 87.5% in Michigan, and the behavior therapy rate varied from 32.5% in Tennessee to 60.6% in Hawaii.
The researchers advocate more research to clarify the impediments to providing behavior therapy for ADHD, especially in preschool-aged children.