Malachi Nelson - 1

Malachi Nelson
Professor Nancy Elliott
English 111
16 November 2014
Childhood ADHD Treatment: Behavioral Therapy or Medication?
Kevin, a ten year old in elementary school, seems like any other child: his parents work
two full-time jobs to pay the bills and save for his college, they want him to get good grades so
that he can get scholarships to reduce the financial burden of continuing education, and so that
one day he can have a satisfying career. However, while all children have been known to be
impulsive at one time or another, interrupting conversation or making a decision without
thinking it through, Kevin seems to make these decisions on a daily basisas though he isn't
absorbing information and learning like his classmates. At the quarterly parent-teacher
conference, the parents learn that Kevin has been disruptive in class, and his grades are
negligiblehe is just barely scraping by with his 'C's.
His parents become concerned, and take time out of their busy work schedules to bring
him to their family doctor. After their physician quickly interviews Kevin and his parents, he
diagnoses Kevin with attention deficit hyperactivity disorder, prescribes Ritalin, and sends
them on their way. In the coming months, Kevin's parents are pleased to learn at the next
conference that Kevin has become more tame during class and that his grades have improved
from 'C's to mostly 'B's with a few 'C's still loitering. Not perfect, but it's a start, they think.
After all, treatments beyond medication such as behavioral therapy would be too much of an
investment in their already busy lives.

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How do medical professionals (hereto referred to as physicians) diagnose ADHD, and
what are challenges associated with diagnosis? Is the answer to Kevin's ADHD found in
medication, or possibly behavioral therapy?
Many of of these challenges have to do with the medical community not understanding
the root of ADHD, so a look into what is being done to better understand it is in order. Low
levels of dopamine transmission in the brain have long been associated with ADHD's
symptoms, and stimulant medications commonly prescribed by physicians increase
transmission. Dopamine is the rewards chemical of the brain, and it improves one's drive to
learn. For instance, when a child studies his math homework, takes the test, gets an A, and is
rewarded with extra allowance from his parents, the child is likely to study his homework in
the future with more effort. It has been hypothesized that ADHD causes low dopamine
neurotransmission levels in a child's brain, resulting in the child having hyperactive and
inattentive behavior.
Researched has shown that while medication may effectively treat hyperactivity,
behavioral therapies involving token reinforcement have been shown to be more efficacious
than medication in improving academic performance (Flora, p.85). Why is this? Personal
improvement comes from one's development as a person, rather than through changing one's
chemical brain processes with medication. And while medication may improve focus almost
instantaneously, behavioral therapy can also improve focus, though it takes more time.
Today's treatment of ADHD through medication is effective in the short-term, but not in
the long-term, since it addresses the chemical causes of ADHD but not the behavioral
symptoms.

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ADHD in the Societal Pressure-Cooker
In order to understand how ADHD is diagnosed and treated today, we first must
understand the societal pressures that affect them. Societal pressures negatively affect accurate
diagnosis and effective treatment of ADHD, so while today's subjective diagnosis methods and
pharmaceutic treatments of ADHD are adequate in the short-term, discovering the biological
cause and presentation of ADHD would help improve diagnosis and treatment of individuals to
better meet needs for long-term improvement.
ADHD's Diagnosis
According to the Diagnostic and Statistical Manual of Mental Disorders, a manual used
in the mental health professions in the US, Kevin's physician should take the time to interview
parents and teachers to evaluate the behavior of the child in question. The physician should also
observe the child himself.
As noted in the beginning vignette, a 20 minute consultation was all it took to diagnose
Kevin's ADHDhardly the amount of needed time expected to diagnose a live-changing
mental disorder. However, due to an increase in regulations, business challenges, and
uncertainty with the extensively complex Affordable Care Act (Bendix, et al., p.1), 20 minutes
is all most physicians can take with a patient. An outpatient consultation can be up to 80
minutes in length, but it is common for a physician to take just enough time to briefly conduct
interviews and send the parents and child on their way (Barkley, p.7; Hill, p.17; Keorth-Baker,
p.2).
In addition to societal pressures, ADHD doesn't present itself like cancer, which gives
biological symptoms for a doctor to diagnose (Monastra, p.13). Thus, observation of the child

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and interviews with parents, teachers, and the child are the next most viable methods of
diagnosis. The Diagnostic and Statistical Manual of Mental Disorders identifies three possible
presentations of ADHD, each with their behavioral symptoms which must often present
themselves and limit Kevin's ability to function in his daily environments (Monastra, p.10).
The dependance on the word 'often' to define the 'symptoms' of ADHD reduces the
disorder to one of personal taste, having nothing to do with any scientific, medical, or objective
criteria (Flora, p.77; Monastra, p.13). The differing of opinions between interviewees (i.e.
parents, teacher, and child) confounds diagnostic efforts, and a more evidence-based diagnosis
is needed to increase the accuracy of ADHD's diagnostic process (Monastra, p.14). Since the
criteria to diagnose ADHD is purely subjective, it calls into question the value of using in-depth
interviews.
The 20 minutes a physician takes with the family are enough for a child exhibiting
symptoms related to ADHD to be loosely diagnosed with ADHD, given a drug, and asked to
come back in 4 weeks to see if anything has improved (Koerth-Baker, p.2).
While physicians are encouraged to first try non-pharmaceutical treatments (like
behavioral therapy) to treat ADHD, 87% of visits to the physicians resulted in medication to
treat ADHD (Kraly, p.230).
Is this rate of medication prescription justified, or is behavioral therapy a viable option
that has been overlooked in today's fast-paced society? According to the literature, 70% of
medication prescribed to children is effective on the first attempt, and 80%-90% of
prescriptions are responded to favorably. When we compare it to the pharmaceutic reception of
other mental disorders, this is a impressively high success rate (Kraly, p.216-217).

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But what about the 10%-20% of children who don't respond well to medication? In
addition to academic challenges, appetite suppression, sleeplessness, and even hallucinations
are possible side effects if a child doesn't respond well to medication (Schwarz, p.1). For
parents, this raises the question of whether a different drug should be tried, a combination of
drugs, or perhaps something else? In addition, the long-term use of medication has not been
shown to improve negative attitudes overall (Flora, p.93). With this in mind, how can long-term
behavioral issues be addressed? Is behavioral therapy an appropriate answer to this
conundrum?
In a 2007 study, it was shown that while medication and combined treatment
(medication and behavior therapy) began as superior to behavioral treatment, within 36 months
all three treatments had about the same level of effectiveness (Clay, p.2). Thus, behavioral
treatment, with time, does just as well as medication in treating ADHD. One behavioral therapy
techniqueproviding a child with immediate feedbackwas illustrated in a study: a teacher
found a creative way to engage a child with ADHD by giving him a math sheet with the
answers written in invisible ink. He was told to color the sheet until he found the answers. The
results were encouraging: every question was answered, and 84% of the questions were
answered correctly. By taking the time to find a way to interest and engage students with
ADHD, teachers can help them succeed academically (Clay, p.1) Behavioral therapy
interventions like parent and teacher programs and therapeutic recreational programs (like a
summer camp) are effective, but only so long as they are consistently continued (Clay, p.2).
If behavioral therapy can be so effective, what is preventing its implementation in
today's culture?

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Kevin's parents, aware of the increasing cost and competition of college, are pushing
him to work harder and be smarter in school to increase his chances of getting scholarships
(Koerth-Baker, p.4). One day, they want to see him support himself in a fulfilling career
without taking crippling educational loans from the bank. While behavioral therapy may help
achieve these goals in the long run, they are working two jobs to save for their future as well
retirement gets closer every year, and they need to be prepared when it is time to leave the
workforce. It would be difficult to invest the extra time, money, and effort to hire a behavioral
therapist, develop a strategy, implement it, and adjust it as needed. As noted above, it can take
up to 3 years to achieve the success that medication.
The cost of education continues to rise at the elementary and secondary levels,
pressuring Kevin's teachers to find more efficient ways to teach and manage childrenthis
places children like Kevin at a disadvantage, as they are harder to both teach and manage.
Policies such as the No Child Left Behind Act have incentivized schools to give difficult
children ADHD's label, which helps to school receive more federal funding (Koerth-Baker,
p.3).
These cultural forces pressing upon physicians, teachers, and parents have all but
crushed the potential for more effective, though slower-acting behavioral therapies, and are
alleviated through the ease of fast-acting medication, but some families are left without
treatment due to negative side-effects of medication. So on one hand, we have medication,
which manages hyperactive behavior in a low-cost and mostly effective manner. It's effects
aren't long-term, as medication doesn't improve a child's personality or character. One
treatment is ineffective and harmful for 10%-20% of children, while the other is untenable for

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most parents and teachers in today's culture.
Though treating ADHD through medication is effective for 80%-90% of children, the
medical research community should not sit on its haunches, but instead work to increase
medication's effectiveness (Kraly, p.236).
A better understanding of ADHD's root causes may be the key to this seemingly bleak
puzzle. Discovering its roots will help prevent misdiagnosis on the part of physicians; doing so
will also help develop more accurate methods of treatment, whether presented as advances in
pharmaceutic care or in verifying the need for a change to behavioral therapy.
Recent research is probing into the brain to find ADHD's root. What if it wasn't due to
the lack of dopamine transmission in the brain, but the result of something else? In 2013,
Cambridge released research which linked the roots of ADHD not to a lack of dopamine
transmission, but due to a significant loss of grey matter in the brain (Campo, et al., p.32663267). What are the possibilities of this research? Continuing down such a path of research
may reveal specific markers in the brain that indicate a positive diagnosis of ADHD. If this is
the case, then it would be possible to scan a newborn baby's brain and diagnose ADHD. Having
such a method would reduce misdiagnosis drastically
Evidence has found a correlation between a child having ADHD and a blood relative of
that individual also having ADHD. In fact, individuals with ADHD are four times more likely
to have a relative with ADHD (Martin, 2007). The more studies done, the more scientists are
hypothesizing that ADHD has strong roots in genetics (Barkley, p.1). If ADHD's specific root is
genetic, then determining the genes of a child during a pregnancy will give the parents time to
decide how they will change their lifestyle to meet the needs of their child.

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As discussed above, since no physical signs have yet been discovered to diagnose
ADHD, it's diagnosis through interviews and observation subjective is of little worth to
physicians, and are time-consuming in a culture which doesn't allow for inefficiencies. As a
result, low-cost medication is commonly prescribed to treat ADHD's short term issues, and
behavioral therapy has been left on the back burner for lack of tenability in today's society. The
10%-20% of children falling between the cracks of today's medication must be caught, and we
can do that by making more effective medication with less side effects. Discoveries about the
root of ADHD, be it genetic, hidden deep in the intricacies of the brain, or in some other form,
are bringing us closer to the root cause of ADHD, and it is imperative that such studies
continue. With such studies, we can only hope that what is seen as a poorly understood
challenge for Kevin today will be seen as an issue overcome tomorrow.

Malachi Nelson - 9
Works Cited
Barkley, Russell. No interviewer given. No ed. Medicating Kids. CBS, 2001. Web.
Transcript.

Bendix, Jeffery, Daniel R. Verdon, Alison Ritchie, Donna Marbury, Chris Mazzolini.
Top 10 challenges facing physicians in 2014. Medical Economics. December
25, 2013. Web.

British Association for Psychopharmacology. Child and learning disability

psychopharmacology. No ed. Journal of Psychopharmacology 11.4 (1997)
291-294. Web.

Bussing, Regina, Bonnie T. Zima, Dana M. Mason, Johanna M. Meyer, Kimberly

White, Cynthia W. Garvan. ADHD Knowledge, Perceptions and Information
Sources: Perspectives from a Community Sample of Adolescents and their
Parents. No ed. The Journal of Adolescent Health 51.6 (2012) 593-600. Web.

Clay, Rebecca A. Easing ADHD without meds. No ed. The Monitor on Psychology
44.2 (2013) 44. Web.

Flora, Stephen Ray. Taking America off Drugs: Why Behavorial Therapy Is More
Effective for Treating ADHD, Depression, and Other Psychological Problems.

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No ed. Albany, NY: SUNY, 2007. 71-93. E-book.

Hill, Emily. Time Is on Your Side: Coding on the Basis of Time. No ed. Family
Practice Management 15.9 (2008): 17. Web.

Koerth-Baker, Maggie. The Not-So-Hidden Cause Behind the ADHD Epidemic. New
York Times. Ed: Dean Baquet. Nov. 2013. Web.

Kraly, F. Scott. Psychopharmacology problem solving: principles and practices to get it

right. No ed. New York, NY: W.W. Norton, 2014. Pages 216-236. Book.

Martin, Ben. Causes of Attention Deficit Disorder (ADHD). No ed. Psych Central.
2007. Web.

Monastra, Vincent J. Unlocking the potential of patients with ADHD: a model for
clinical practice. No ed. Washington, DC: American Psychological Association,
2007. Pages 9-26. Book.

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Critical Preface:
This annotated bibliography was compiled to compare the different methods of
treatments for ADHD, namely behavioral-based treatment and pharmaceutic treatment, to
answer the question, Is behavioral therapy more effective than pharmaceutic treatment?
The research was collected between mid-October, 2014, to November 4, 2014. The ten
sources compiled consist of three books, four articles from clinical journals, one CBS
television interview, an article from the New York Times, and an article from an online
magazine, Psych Central.

British Association for Psychopharmacology. Child and learning disability

psychopharmacology. No ed. Journal of Psychopharmacology 11.4 (1997)
291-294. Web.
In 1997, the British Association for Psychopharmacology published an informative
report in the Journal of Psychopharmacology for those subscribed to the Journal on the use of
medication to treat mental disorders like OCD, depression, schizophrenia, learning disabilities,
and ADHD. The article includes summaries of research studies concerning treatment of the
previously mentioned disorders through various medications, the need for effective diagnosis of
disorders to reduce stigma against mental disorders, suggestions for combining
pharmacological treatments with psychological treatments, and a call to treat patients on a caseby-case basisrather than stubbornly adhering to a single treatment regardless of patient
results. It is a potentially useful article that one could use to frame the current issues with
ADHD, as it takes a balanced view toward different treatments for ADHD.

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Bussing, Regina, Bonnie T. Zima, Dana M. Mason, Johanna M. Meyer, Kimberly

White, Cynthia W. Garvan. ADHD Knowledge, Perceptions and Information
Sources: Perspectives from a Community Sample of Adolescents and their
Parents. No ed. The Journal of Adolescent Health 51.6 (2012) 593-600. Web.
In 2012, Regina Bussing, et. al. published an informative research article in the Journal
of Adolescent Health for the journal's readers on the general public's perception of ADHD. The
article interviewed participants regarding their general knowledge of ADHD, misconceptions
about the causes of ADHD (sugar and medication overuse), and where participants received the
majority of their information regarding ADHD, and the article suggests that doctors make it a
priority to spend enough time with clients to adequately provide information and reputable
websites regarding ADHD. The article provides recent findings of the general public's view
regarding ADHD, which would be useful to illustrate the importance of educating the public,
but it doesn't provide a satisfying conclusion on how to better educate the public.

Barkley, Russell. No interviewer given. No ed. Medicating Kids. CBS, 2001. Web.
Transcript.
In 2001, CBS's Frontline interviewed psychologist Russell Barkley, providing the
viewer with a glimpse of what is happening biologically in the mind of a child with ADHD.
Barkley, an expert regarding ADHD, contends that one with ADHD has a physical difference in
the brain (though he admits that scientists haven't yet found a biological marker for ADHD),
which causes a lack of self-control in those affected by it, advocates the use of medication to

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treat ADHD, the need for and difficulties facing proper diagnosis, education, medication, and
behavior modification of ADHD, and his understanding of how stimulant medications work.
Russell seems derisive toward those opposed to pharmaceutic treatments for ADHD, but
clearly knows what he is talking about in regards to ADHD, and the interview is a strong piece
of evidence providing a well-rounded understanding of ADHD and pharmaceutic treatment.

Clay, Rebecca A. Easing ADHD without meds. No ed. The Monitor on Psychology
44.2 (2013) 44. Web.
In 2013, Rebecca Clay wrote the informative article Easing ADHD without meds in
The Monitor on Psychology, to keep the general public abreast of research being performed
concerning ADHD. In the article, Clay notes that research has recently been performed which
shows that behavioral treatments which give immediate feedback to children with ADHD
increases their attention without the use of medication, and informs the reader of treatments
that have been shown to be effective in treating ADHD, such as rewards-based interventions
and exercise. The article seems balanced, with no glaring biases presenting themselves, and it
would be a reasonable end to an argument for behavioral treatments of ADHD.

Flora, Stephen Ray. Taking America off Drugs: Why Behavorial Therapy Is More
Effective for Treating ADHD, Depression, and Other Psychological Problems.
No ed. Albany, NY: SUNY, 2007. 71-93. E-book.
In 2007, Stephen Flora wrote the book Taking America off Drugs: Why Behavorial
Therapy Is More Effective for Treating ADHD, Depression, and Other Psychological

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Problems, an informative and persuasive book attempting to show that disorders like ADHD
are best treated with behavioral modification techniques rather than medication. Flora argues
that the diagnosis of ADHD is clinically nonobjective, with symptoms evaluated subjectively
by the physician, the danger of the drugs used to treat ADHD, and proposes a return to
intensive behavioral treatments in lieu of pharmaceutic treatments. Flora is a psychology
professor at Youngstown State University, teaching behavioral intervention techniques, which
gives his writing a strong bias toward behavioral therapy, and the book would be useful in
supporting a move toward behavioral therapy as opposed to pharmaceutic treatments.

Koerth-Baker, Maggie. The Not-So-Hidden Cause Behind the ADHD Epidemic. New
York Times. Ed: Dean Baquet. Nov. 2013. Web.
In 2013, Maggie Keorth-Baker wrote a persuasive article in the New York Times to the
general public, postulating that societal changes have brought about the ADHD epidemic. She
notes that the rise in the diagnosis of ADHD is positively correlated with changes in society's
rapidly increasing expectations for children, aided by the lack of an objective diagnostic
approach to ADHD and the incentivizing of mental disorders like ADHD through laws like the
Individuals with Disabilities Education Act and the No Child Left Behind Act. Keorth-Baker's
article is balanced, acknowledging the unknowns of ADHD and the US's societal role, but also
presenting a logical and reasonable hypothesis for the root cause of ADHD.

Kraly, F. Scott. Psychopharmacology problem solving: principles and practices to get it

right. No ed. New York, NY: W.W. Norton, 2014. Pages 216-236. Book.

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In 2014, Scott Kraly wrote the book Psychopharmacology problem solving: principles
and practices to get it right, published by W.W. Norton, which contained a chapter on treating
ADHD with medication. Kraly writes that in comparison to pharmaceutic treatment of other
mental disorders, the pharmaceutic treatments of ADHD have a high rate of success, though the
long-term effects are poorly understood, and theorizes that the use of medication for ADHD is
increasing due to societal pressures and the monetary efficiency of medication over behavioral
therapy. In Psychopharmacology's introduction, Kraly states that he wants to show the
strengths and weaknesses of psychopharmacology in treating mental disorders, and achieves
that goal in his chapter on ADHD, so his book would be useful in concluding arguments for the
use of medication in treating ADHD.

Martin, Ben. ADD/ADHD Overview: Treatment of ADHD and Additional Treatments

of ADHD. No ed. Psych Central. Web.
In 2007, psychologist Ben Martin wrote an informative article for the general public in
Psych Central, an online database written by experts in the field of psychology, in which he
explains options for treatment of ADHD. He begins by establishing that research has suggested
the best way to treat ADHD is through psychotherapeutic and pharmaceutic treatments,
explains medications available to treat ADHD, their effectiveness and possible side effects as
supported by research, and alternative treatments for ADHD including parenting training,
social skills training, and support groups. Overall, the article is balanced, giving the reader a
better understanding of treatments available for ADHD, and would be an effective bookend to
the issue of proper treatment of ADHD.

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Partridge, Brad, Jayne Lucke, Wayne Hall. Over-diagnosed and over-treated: A survey
of Australian public attitudes towards the acceptability of drug treatment for
depression and ADHD. No ed. Biomedical Central Psychiatry 14.74: (page
range here). Web.
In 2014, Brad Partridge, Jayne Lucke, and Wayne Hall wrote a research article in the
journal Biomedical Central Psychiatry for the general public about Australian attitudes toward
treating depression and ADHD with medication. The research consisted of a survey of
Australian households, finding that the majority of respondents considered medicating
depression as acceptable, but only a minority of respondents considered medicating ADHD as
acceptable, and the article concluded by stating that the lack of public education on ADHD may
decrease the effectiveness of treatment of ADHD through medication. The article is predisposed toward treatment of ADHD through medication, and is a study of the Australian
people rather than US citizens, but would be useful in showing the importance of proper public
education of mental disorders.

Sudak, Donna. Combining CBT and Medication: An Evidence-based Approach. No ed.

Hoboken NJ: Wiley, 2011. 1-8. E-Book.
In 2011, Donna Sudak wrote the book Combining CBT and Medication: An Evidencebased Approach, published by Wiley for the general public, in which she argues for the use of
medication and behavioral therapy to treat mental disorders. In the chapter Medication Versus
CBT: How Did That Happen? Sudak explains that the effectiveness of CBT (combined

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behavioral therapy) in treating patients with mental disorders has been negatively skewed by
research projects, which, when comparing CBT to medication when treating mental disorders,
do not include patients with the presence of a comorbidity, though patients with a comorbidity
benefit the most from CBT, and Sudak ends stating that reintroducing CBT as part of the
treatment for mental disorders on a case-by-case basis would improve their treatment. Sudak's
arguments are well-supported and based on her own experience, and would be useful in finding
the middle ground between treatment of ADHD through medication and psychotherapy.

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Outline:

Introduction

Societal pressures on diagnosis and treatment of ADHD

Policy pressures on physicians in society promote less diagnosis time.
Policy pressures on teachers to teach the class more effectively with less money
promote treatment through medications.
Time and money crunches on parents promote treatment through medications
These same crunches dissuade behavioral therapy as it requires extra time, effort,
and money to be effective

Diagnosing ADHD
Remind of societal pressures
DSM-V criteria are ineffective markers for ADHD.
The criteria are subjective: interviews and observation. This doesn't provide
good reason for physicians to properly perform the DSM-V recommendations. It
is easier to diagnose ADHD and see what happens. (Koerth-Baker)

Illustration: 5% of time, ADHD's diagnosis is changed to some other mental

disorder. (Monastra)

Treating ADHD through behavioral therapy

It is the proven long-term approach.
Investing in appropriate behavioral therapy can pay off. (Clay)
However, investing is not conducive in today's society for most people.

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Treating ADHD through medication

Remind of societal pressures
Cost-effectiveness and quick action incentivize care through medication.
Unknown possible side effects and ineffective medication leave the public uneasy
Weakness: does not improve the child's personal development over the long run.

Research must continue to explore ADHD's root causes and test the safety of adhd to
improve effectiveness of medication and to keep kids safe.