ADHD Meds Work Better Than Behavioral Parent Training for ADHD Symptoms! Case Closed!

You would think from the article in Mental Health Weekly, based on a report from and interviews with CDC officials, that behavioral parent training (BPT) was as effective as medication for management of young children with ADHD. Alas, sadly, this is not true. It is yet another example of the CDC speaking to the press about their findings and implications without doing more careful scholarship or talking with those of us who do know the science on ADHD and its management.

First, understand that BPT was designed for, and is most effective with, helping parents manage oppositional, defiant, and noncompliant behavior. It was not designed for, and is not very effective in managing the symptoms of ADHD specifically (inattention, impulsivity, hyperactivity, and executive function deficits). Every meta-analysis of BPT for ADHD has found this to be the case, including the one in 2013 by Ed Sonuga-Barke and colleagues. But no major researcher working in ADHD, including myself, ever claimed it did in the last few decades.

We have known since the 1980s that BPT is not very helpful for ADHD symptom management. BPT is based on social learning theory and the idea that much of child misbehavior is the result of faulty learning and disrupted parenting. It targets compliance and cooperation, not inattention and impulsivity.

There is some truth to the involvement of parenting in the genesis and maintenance of oppositional, defiant, and noncompliant behavior. There is no truth to that in ADHD. Thus, from both a theoretical and practical viewpoint, BPT would not be expected to manage ADHD symptoms very well, if at all. What studies find is that parenting improves while child symptoms improve very little—and when they do improve, the improvement is not maintained after treatment (see ScienceDirect). My own parent training books on defiant children make this point specifically in their introductory chapters. BPT is for ODD, not so much for ADHD symptoms.

The CDC should certainly have known this given the findings of the Preschool ADHD Treatment Study (PATS), done 10 years ago to study the safety and effectiveness of stimulant medication for preschoolers with ADHD. This is the largest study ever done on this issue. It required that all children and their parents get BPT before entering the medication trial so that only those whose ADHD symptoms did not respond to BPT could get medication. This is precisely what the CDC is arguing for in this article. What was found? At least 55% of the preschool children still had to enter the medication trial because BPT didn't help them much, if at all.

Don't blame the journalist, Valerie Canady, for this error. She is reporting only what she was told. It is the CDC professionals who should be blamed for this error. For instance, Anne Schuchat, M.D., principal deputy director at the CDC, said during the briefing, “Behavior therapy has been shown to help improve symptoms in young children with ADHD and can be as effective as medicine but without the side effects.”

That is false! To state this is to show you do not know the actual literature on BPT for ADHD in children. It also shows she did not read the PATS study or look across the available reviews of the literature. The degree of improvement from BPT on ADHD symptoms is far below that seen in studies of medication. And even those effects of BPT on children are not sustained over time very well.

So to require that all young children undergo BPT first before getting medication is to require a less effective therapy that is not widely available be initiated before a more effective therapy. It is also to believe that BPT is widely available in the U.S. when it is not. No wonder that physicians are treating more young children with ADHD with medication than are getting BPT as the CDC found. They are leading with their most effective therapies first.

The CDC needs to stop making parents and physicians feel guilty about using medications to manage ADHD and certainly stop purveying the idea that BPT is as effective as medication for ADHD children. It just isn't so.

Yes, parents should be encouraged to get BPT, especially if their child has oppositional defiant disorder, which many do. But don't promise them that BPT will be as effective as medication, because it won't be. Tell them BPT is for reducing family conflict. Other interventions will need to specifically target the ADHD and EF symptoms, medication among them.

Russell A. Barkley, Ph.D., author of Your Defiant Child and Your Defiant Teen, among many other books on ADHD, is an international authority on ADHD and a clinical professor of psychiatry at the Medical University of South Carolina. This comment appeared as a response to an article on behavioral parent training in Mental Health Weekly.