CDC Telebriefing: New Vital Signs Report – ADHD

OPERATOR: Welcome and thank you for standing by.  All participants will be in listen-only mode until the question and answer portion of today’s conference.  At that time if you wish to ask a question you may do so by pressing star followed by the number 1.  Please limit yourself to one question and one follow-up.  This conference is also being recorded.  If you have any objection, you may disconnect at this time.  i will now turn the conference over to Kathy Harben.  Thank you and please begin.

KATHY HARBEN: Thank you, Gabrielle.  And thank you all for joining us today for the release of a new CDC “vital signs” focused on raising awareness of behavior therapy as the recommended first treatment for young children with ADHD.  We’re joined today by Dr. Anne Schuchat, CDC’s Principal Deputy Director, also by Dr. Georgina Peacock, who is Director of The Division of Human Development and Disability, and Dr. Susanna Visser, author of the report and a lead epidemiologist in CDC’s division of human development and disability.  Drs. Schuchat and Peacock will give opening remarks, and then join Dr. Visser for the Q&A.  I’ll now turn the call over to Dr. Schuchat.

DR. SCHUCHAT: thanks so much.  And thank you all for joining us today to discuss our new “vital signs” report on treatment for attention-deficit/hyperactivity disorder, or ADHD, in young children.  CDC works 24/7 to protect the health, safety and security of all Americans.  One of the ways we do this is by monitoring health trends and working to address health threats.

This vital signs report contains important information on current and recommended treatments for young children, 2 to 5 years of age, with ADHD.  The bottom line is that we know parents want to do what’s best for their children and we want to support health care providers and parents of young children with ADHD.  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.

We know that medicine will be appropriate for some young children, but we encourage pediatricians, therapists, and other health care providers to work with families to make sure children with ADHD are receiving the most appropriate treatment, and this should include a discussion about behavior therapy as the first step.

In this month’s “vital signs” we’re drawing attention to behavior therapy, which is an important and recommended first step for young children with ADHD.  Behavior therapy is a form of treatment in which parents learn specific ways to improve the behavior of their young child with ADHD.  This treatment can work as well as medicine, and without the risk of side effects in young children.  And research shows the benefits of behavior therapy can last for years.

Parents can feel overwhelmed with decisions about their child’s treatment for ADHD.  The good news is that parents aren’t in this alone.  Healthcare providers including therapists and families can all work together to help the young child with ADHD thrive.  Parents of young children with ADHD need support, and behavior therapy is an important first step.  We’re still learning about the potential side effects of long-term use of ADHD medicine on young children.  Until we know more, the recommendation is to first refer parents of children under 6 years of age who have ADHD for training in behavior therapy.

First, I’ll share background on ADHD in young children and the current recommended treatments.  About 6.4 million children in the U.S. have been diagnosed with ADHD.  It’s a biological disorder that can cause children to be overly active and have trouble paying attention or difficulty controlling their behavior.  Parents do not cause their child’s ADHD, but parents play a key role in the treatment of their child’s ADHD.  About 2 million children with ADHD were diagnosed when they were only 2 to 5 years of age.  Children who are diagnosed at these young ages often have the most severe symptoms and their parents often seek additional support.  Since 2011, the American Academy of Pediatrics has recommended that healthcare providers refer parents to training in behavioral therapy first, before prescribing medicine to a young child.  However, according to the “vital signs” report, only about half of young children received any form of psychological services, which might have included behavior therapy.  In contrast, about 3/4 of young children who were being treated for ADHD received medicine.

Why is this important?  We want healthcare providers and parents to have the information they need to make the best treatment decisions for their children with ADHD.  Research shows that when parents are trained in behavior therapy it can be as effective as ADHD medicine in young children, without the risk of health side effects.  Side effects of ADHD medicines include poor appetite, stomachaches, irritability, sleep problems and slowed growth.  Also, we don’t know about the long-term effects of these medicines on young children.  That’s why behavior therapy is the recommended first step in the treatment of young children with ADHD.  Behavior therapy may require more time, energy and resources than medicine.

But the effects of behavior therapy can be longer lasting.  We know that, unfortunately, behavior therapy may not be available in every community.  We know there’s work to be done to increase availability.  State and local governments, healthcare professional organizations and insurers can work together to increase these options for families.  You can go to our website www.CDC.gov/vitalsigns for links to information on finding a behavior therapist in your area or what to look for in a behavior therapist.  Here are some details about the report we are releasing today.

Today’s MMWR provides trends in psychological treatment, which may include behavior therapy, and trends in ADHD medicine use over time.  We used healthcare claims data from 5 to 7 million young children 2 to 5 years of age insured each year by Medicaid from 2008 to 2011, and claims data for about 1 million young children insured each year through employer-sponsored insurance, which is the most common form of private insurance.  We had employer-sponsored insurance data for a longer period, 2008 to 2014.  So for those children with employer-sponsored insurance we compared treatment rates for ADHD in the years before and after release of the 2011 American Academy of Pediatrics guidelines to see if there were any increases in the use of psychological services or drops in medicine use.  We found that for the years 2008 to 2014, regardless of insurance type, no more than 55 percent of children with ADHD received psychological services, and just over 3/4 received medicine.  Looking at treatment a little more closely for those children with employer-sponsored insurance, according to the 2014 data for young children in clinical care for ADHD, only 42 percent of children received psychological services and 76 percent received medicine.  So less than half of children with employer-sponsored insurance in care for ADHD received any form of psychological services.  We did not find any increase in the use of psychological services after the 2011 American Academy of Pediatrics guidelines were released.  In fact, there was a small decrease in the percentage of children receiving psychological services.  Medicine treatment rates did not change during this period.  These data suggest we are missing opportunities for young children with ADHD to receive behavior therapy.  Increasing referrals and the availability of appropriate services could help many families with young children who have ADHD.  Now I’d like to turn things over to Dr. Peacock, who’s going to explain a little bit more about behavior therapy for young children.

DR. PEACOCK: Thank you, Dr. Schuchat.  I am a developmental pediatrician and I routinely work with young children and parents, some of whom are struggling with ADHD.  When we talk about young children with ADHD, we are talking about children with challenging behaviors.  By the time a parent comes to meet with me, they are tired and worried about their child.  They are concerned their child might jump down a flight of stairs, that the child could get lost in a grocery store, or that the child could be kicked out of preschool.  One of the tools to help these parents is what we are talking about today — behavior therapy.  This kind of therapy has two parts.  It strengthens the relationship between the parent and child, and it gives parents more effective tools for helping their child learn positive behaviors.  How does behavior therapy work?  Behavior therapy is like having your own personal coach for dealing with challenging behaviors.  A behavior therapist teaches parents how to provide positive attention, and set and communicate rules.

Sometimes a therapist works directly with a parent and child.  Other times, the therapist meets with a group of parents. Parents will go home and practice techniques, and then go back to the therapist to talk about what worked and what didn’t, and learn new skills to practice again.  Typically, parents meet with a therapist for eight or more sessions. Parents who use the strategies report their children learn to better control their own behavior, which helps the child at school, at home, and in the child’s relationships with other people.  It takes work, time and effort, but the benefits can be lifelong.  We can’t tell you what will work for each individual child, and we recognize that treatment decisions are best made when there is a discussion that happens between a parent and the child’s doctor.  In some cases medicine will be part of the discussion.  We can tell you that behavior therapy is a proven tool that can make a huge difference for a child with ADHD.  Thank you.

DR. SCHUCHAT:  So today’s report suggests we’re missing opportunities for young children with ADHD and their parents to benefit from behavioral therapy.  We all can play a role in helping parents get the information and services they need.  So now I’d like to turn it back to the moderator so that we can begin the question and answer period.

KATHY HARBEN: Thank you, Dr. Schuchat and Dr. Peacock. Gabrielle, we are now ready for questions.

OPERATOR thank you.  At this time if you wish to ask a question please press star followed by the number 1 and record your name when prompted.  Do please limit yourself to one question and one follow-up.  Again, to ask a question please press star followed by the number 1 now.  One moment, please, for the first question.  Questions are coming in.  One moment.  We have a question on the line from Mike Stobbe with AP.  Your line is open.

MIKE STOBBE: Hi.  Thank you for taking my questions.  I just wanted to clarify.  In the analysis when they talked about medicines, were they talking about something specifically, methylphenidate or all psychostimulant medications that are used for ADHD?  And then I had a follow-up question.

DR. PEACOCK:  Thanks, Mike.  The analysis used all FDA-approved medicines for ADHD.  So it was more than one category.  Your follow-up question?

MIKE STOBBE: My follow-up is what does the FDA recommend — the FDA does not recommend these medications for kids under 6, is that correct?  Or what is the FDA recommendation regarding these for preschoolers?

DR. PEACOCK: Dr. Visser’s going to answer that question.

DR. VISSER: Yes.  Short-acting amphetamine formulations have been approved for children as young as 3 years of age.

MIKE STOBBE:  Okay.  So some have.  Thank you.

KATHY HARBEN: Next question, please.

OPERATOR: our next question comes from Matthew Herper with “Forbes.”

MATTHEW HERPER:  So these are minimums for both the number of people who get medicine and whether they get any psychological therapy at all.  But what is the — what is the evidence, if you could describe it, for behavioral therapy?  I mean, you said that it’s significant.  But is there a particular type that should be being used?  And just in kind of throwing my follow-up in, do we have any information over whether insurers have embraced providing behavioral therapy at all?  I mean, is this something that is reimbursed or paid for in private insurance?  I’m struck that the numbers in private insurance seem lower than those in Medicaid.

DR. SCHUCHAT:  Yes, thanks.  That was a couple questions.  Let me begin and then let Dr.  Visser supplement.  You mentioned these are minimum estimates, but I need to clarify.  This is claims data. The psychological services may overestimate the number of individuals that are actually getting behavioral therapy because it’s a broader categorization.  It wasn’t possible with the claims data to make sure that the psychological services were the recommended type.  But as you say, these are minimums in terms of people might have been getting either behavioral therapy or medications and not having claims for them, in particular in private insurance.  Parents might have been seeking behavioral therapy or medications without submitting claims.  In terms of what’s recommended, our website goes into more detail about that.  But behavioral therapy for ADHD is quite specific.  It can be either training the parents individually or in groups.  But it is different from things like talk therapy or play therapy.  And then your last question was about the insurers.  And essentially, insurers should cover this.  We believe that Medicaid really makes an effort to make sure that the full package of recommended behavioral services are covered.  But there still may be some variations state to state.  And private insurers may also vary.  So you noted that there’s a higher proportion of children in the Medicaid claims data receiving the psychological therapy or services than in the employer-sponsored insurance.  That may be because the coverage is better, or it may be because the individuals are getting claims through the Medicaid.  Or it may be because the populations differ in their risk factors.  Did you want to say a little bit more about the type of treatment, Dr. Visser?

DR. VISSER: You did a good job.

KATHY HARBEN: Okay.  So next question, operator?

OPERATOR: our next question will come from Kimberly Leonard with “U.S. News & World Report.”

KIMBERLY LEONARD: Hi.  Thanks for taking my call.  I just wanted a little bit of clarification as to be there any point at which medication is recommended?  Is it once behavioral therapy has been tried, or is it — do you really recommend against use of medication in such a young age group?

DR. SCHUCHAT:  You know, I’ll begin, and then Dr. Peacock, who’s cared for a lot of these families, will expand.  You know, our bottom line is that there’s been an evidence-based review that suggests behavioral therapy is as effective as medicines and in this young age group we don’t know the long-term effects that medicines might have.  We do know about some short-term side effects.  And so similar efficacy without risk of the side effects is why the American Academy of Pediatrics has recommended that clinicians first refer for behavior therapy.  We know that some children will need and benefit from medicines.  And Dr. Peacock can talk you through that.

DR. PEACOCK: Sure.  And as Dr. Schuchat said, these decisions are really best made when there’s a discussion between a parent and the child’s doctors.  There are cases in which medicine will be part of that discussion.  The recommendations are that pediatricians talk with parents about behavioral therapy first because that really lays the foundation, helps build skills, and this could change over life too.  There may be times when medicine will be added to the treatment.  But having this behavioral therapy first really will make a difference for families.

KIMBERLY LEONARD: And there’s short-term effects — again, I’m sorry.  I just want to follow up on that.  So if they’re receiving behavioral therapy at such a young age, is it possible that they’ll never need to be medicated?  And also, the short-term effects, can you remind me how severe those are?

DR. SCHUCHAT:  Right.  The issue of the side effects can vary, of course, for each child.  But the list of them includes poor appetite, which can sometimes actually lead to slower growth.  Stomach aches, irritability, and sleep problems.  And every child is different, and the medicines may affect them differently.  But those are the short-term side effects.  The question of whether children who have ADHD diagnosed at an early age will be able to benefit from behavior therapy without ever need medication, Dr. Peacock can probably comment on.

DR. PEACOCK: It is possible that some children will not need this.  And really we can’t really talk about individual children, and talking with — the parents should talk with the pediatrician about what’s best for every child.

DR. VISSER: And I guess again to just emphasize that the evidence base in this very young age group about the long-term risks and benefits of medicines is not as large as it is for older children.  and so today’s report is really emphasizing the situation for the 2 to 5-year-old age group where some of the more severe episodes of ADHD can be recognized, and so it’s in that context where that first line recommendation for behavior therapy’s so important.  And frankly, it can help the family get skills that will serve them well whether or not the child eventually needs medicine.

KATHY HARBEN: Operator, next question?

OPERATOR: Our next question comes from Steven Reinberg with “HealthDay.”  Your line is open.

STEVEN REINBERG Yeah.  If insurance doesn’t cover behavior therapy, any idea what the cost is?

DR. SCHUCHAT: You know, this will vary state to state and service to service.  We do know that some providers, in particular university training centers, will offer sliding scales.  And you know, one of our points of raising this awareness today is to really let the insurers know that this evidence has been reviewed carefully, that the American Academy of Pediatrics has looked at it, you know, five years ago and we all really feel this is an appropriate intervention that ought to be covered.  But in the meantime some of the providers have sliding scales.  As I mentioned, it’s going to — it’s available for individuals, behavioral therapy for parents, or group therapy.  It’s likely the group sessions are less expensive than the individual therapy.  And CDC is working with partners on efforts to try to expand the availability and perhaps even accessibility through things like future online resources.  Next question, operator?

OPERATOR: our next question comes from Ariana Cha with the “Washington Post.”  Your line is open.

ARIANA CHA: Hi.  I had a quick follow-up question about the — about insurance.  And when you say that these should be covered, are you also talking about kind of the gold standard, which is A.B.A.  Therapy, which is incredibly expensive and usually used for autism but also to address a lot of the same behaviors you that see in ADHD?

DR. SCHUCHAT:  No, you know, the treatments are quite different.  And I’d like Dr. Georgina Peacock to comment on that because we don’t believe the same interventions for autism should be used for children with ADHD.

DR. PEACOCK:  So we are talking about behavioral therapy, but this particular behavioral therapy is parent training.  So parents learn skills that help promote positive behaviors in their children.  There’s also a strengthening of the relationship between the parent and the child.  And some of the other things, some of the examples of things that happen, is parents learn about limit setting.  They learn about applying appropriate consequences for inappropriate behaviors and learn about how to improve communication between the parent and the families.  That’s the type of behavioral therapy that we are talking about and the American Academy of Pediatrics recommends for families.

DR. SCHUCHAT: Next question?

OPERATOR: Our next question will come from Mike Ollove with STATELINE.  Your line is open.

MIKE OLLOVE: Hi.  Thank you very much.  My question is could you talk in more detail about what you see as having been the obstacles to greater participation in behavioral therapy in this area?

DR. SCHUCHAT:  Thank you.  You know, I think this is probably multifactorial.  Some clinicians and parents might not be aware of alternatives to medications.  Medications have been around for a while, and people have heard about them.  So there may be a lack of awareness.  There is an investment of time that parents need to make in order to get the training in behavioral therapy.  And that just might not work for some parents.  We think it’s a good investment of time, but we know that it may not be practical for every situation.  There may be limited availability of the appropriate therapy in a particular area.  We’re aware that some states are working hard with community groups to increase the resources available and to make sure that clinicians are aware of them so that they can make appropriate referrals.  And then I do think that the insurance coverage or the out-of-pocket costs may be a barrier to some.  There have been some comparative cost effectiveness that suggest that after a year behavioral therapy is a better buy than medicines.  Both of them are effective and recommended for different age groups, but we do think that if it’s feasible for parents to work — to fit behavioral therapy into their schedule it can be worth their time and a high payoff for themselves and the family.  But you know, this is really about getting information and services available to parents.  They have a lot going on in managing children with ADHD, and we really want to make their lives easier, not increase their stress with today’s report.  Next question?

OPERATOR: As a reminder to participants, you may ask a question by pressing star followed by the number 1.  One moment, please, for any further questions.  There are no further questions at this time.

DR. SCHUCHAT: Thank you, operator.  And thanks, everyone, who’s been joining us.  Just let me close this out reminding you that we know parents want to do what’s best for their kids and we want to help support health care providers and parents of young children with ADHD to know about all their options.  Behavior therapy has been shown to help improve symptoms in young children with ADHD.  It can be as effective as medicine but without the side effects.  We know medicine will be the appropriate choice for some young children, but we strongly encourage pediatricians, therapists, and others to work with families to make sure that kids are ADHD are receiving the most appropriate treatment, and for young children this should include a discussion of behavioral therapy as the first step.  So thank you for participating, and back to you, operator.

KATHY HARBEN: Thank you, Dr. Schuchat, Dr.  Peacock, and Dr. Visser for joining us today, as well as the reporters who’ve joined us.  For follow-up questions please call the CDC press office at 404-639-3286, or you can send an e-mail to media@CDC.gov.  A transcript of this telebriefing will be posted on the CDC newsroom and vital signs websites, likely later today.  Thank you for joining us.  This concludes our call.

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES