Courtesy of Alex Smith / KCUR

When children are diagnosed with attention deficit hyperactivity disorder (ADHD), stimulant medications such as methylphenidate (Ritalin) or a combination of amphetamine and dextroamphetamine (Adderall) are usually the first line of treatment.

The American Academy of Pediatrics (AAP) issued new guidelines yesterday upholding that central role of medications accompanied by behavioral therapy in ADHD treatment.

Some experts, however, say they are disappointed the new guidelines don’t recommend behavioral treatment first for more children, as that might lead to better outcomes, recent research suggests.

When 6-year-old Brody Knapp of Kansas City, Missouri, was diagnosed with ADHD last year, his father, Brett, was skeptical. He didn’t want his son taking pills.

“You hear of losing your child’s personality, and they become a shell of themselves, and they’re not that sparking little kid that you love,” Brett Knapp says. “I didn’t want to lose that with Brody, ’cause he’s an amazing kid.”

Brody’s mother, Ashley, had other ideas. She’s a school principal with ADHD herself.

“I was all for stimulants at the very, very beginning just because I know what they can do to help a neurological issue such as ADHD,” she says.

More and more families face the same dilemma. The prevalence of ADHD has shot up in the past two decades, and now 1 in 10 children in the United States is diagnosed with it.

Medication’s outsized role:

The new guidelines from the AAP recommend that children with ADHD be screened for mental illness and monitored closely, but the treatment recommendations regarding medication are essentially unchanged from previous guidelines published in 2011.

Anyone over age 5 should start taking medication and get behavioral therapy as soon as they are diagnosed. Children under 5 should start with behavioral treatment before taking any medications.

Still, many experts worry that the role of medication in treatment is too large.

“It’s certainly true that when you watch TV, you’re not going to see a lot of commercials about behavioral treatments, but you very well may see some new ones about medication,” says Carla Allan, an ADHD specialist at Children’s Mercy in Kansas City and a member of the ADHD Clinical Practice Guidelines Subcommittee. Allan is Brody’s doctor and had a role in drafting the latest guidelines. Although she wants to see more children with ADHD receive behavioral treatment, she says, she agrees with the AAP’s decision to hold steady on its recommendations about medication.

Other experts say the guidelines should have done more to prioritize behavioral treatments.

“I think it’s a huge disservice to not just the children that we’re trying to treat but also to the parent who would prefer to have behavioral interventions,” says Erika Coles, associate professor of psychology at Florida International University.

A behavioral intervention can range from cognitive therapy to school support. It can be as simple as parents setting up a system of expectations reinforced by rewards or punishments.

These interventions are designed to teach children strategies they can use on a daily basis to help stay focused and to reinforce social skills that may fail to develop when children struggle to concentrate.

Promising studies:

After school, Ashley Knaap used behavioral techniques to keep son Brody on track with his chores. This is supposed to help him internalize the discipline and “grit” needed to complete difficult tasks, but it can feel to her like micromanaging, she says.

“I don’t like the idea that I have to tell my kids or anybody what to do,” she says. “I want them to be able to think for themselves and make those safe choices, but at this point, that’s just not possible yet for Brody.”

But the techniques — things like counting to keep him on the task of putting away his toys, and rewards like time playing Legos after he finishes a chore — are helping him, she admits.

Although the AAP guidelines advise a combination of medication and behavioral treatment, the research backing this combination is problematic, says Coles, because the two approaches weren’t evaluated separately.

“If you look at studies that did the combined treatment of both medication and behavioral interventions, you can’t disentangle what leads to the best outcome,” Coles says.

A study published in 2016 in the Journal of Clinical Child & Adolescent Psychology explored the sequencing of treatment methods and showed that children with ADHD between ages 5 and 12 who are given behavioral treatment before starting pills have fewer behavioral problems than children who start with pills right away.

A new study co-authored by Coles took it further. It found that children aged 5 to 13 with ADHD who receive therapy first often need less medication. And 37 percent of the children who got therapy first didn’t end up needing to take pills at all.

“Really, what it’s suggesting is that if we use behavioral intervention as the first line of treatment, we can reduce or eliminate the need for medication in children with ADHD,” Coles says.

Less medication also means fewer side effects. Some children who take medications have trouble sleeping, lose their appetite or experience personality changes, and there’s not much research on what it means to stay on these drugs for years, especially when one is still growing.

The studies backing therapy first are promising and compelling, but they are small. Coles’ research looked at 127 children, and the 2016 study evaluated 146.

Not enough therapists:

A spokesperson for the American Academy of Pediatrics ADHD Clinical Practice Guidelines Subcommittee says the group reviewed the recent behavioral-first research but didn’t find the evidence strong enough to warrant a change in the guidelines.

However, both the academy and its critics agree that not enough children are getting adequate behavioral treatment. Only about 60 percent of children with ADHD in the U.S. have ever gotten any behavioral interventions outside of school, whereas 90 percent have received medication, according to a 2018 study published in the Journal of Pediatrics.

Numerous advocates point out that there are not enough trained therapists, the interventions can be time-consuming for families, and many families can’t afford it.

Brody’s family started with behavioral treatments alone, but after four months he experienced a violent meltdown, which made the family decide to give Brody some medication too. He now takes a form of methylphenidate (Concerta).

Brody’s father says he’s okay with that and that doing the therapy first gave him insight.

“It’s not necessarily for the child,” Brett Knapp says of the parental training he received. “It really is for the parent to realize what an ADHD kid looks like. And for the perspective, I think it helped out greatly to kind of realize how I need to interact and how I need to talk and how I need to work with my child.”

This story originally appeared on Kaiser Health News as part of a partnership that includes KCUR and NPR. It has been slightly modified to reflect Spectrum’s style.