What non-drug treatments work to combat attention-deficit hyperactivity disorder (ADHD)?

It's a question more parents are asking doctors, prompted by new concerns about the safety of medicines used to treat a problem that affects an estimated 4.4 million American children.

In the past three months, two advisory committees of the Food and Drug Administration have recommended that warning labels on ADHD drugs, most of them stimulants such as Ritalin, be strengthened because of their possible links to rare cardiac problems and vivid hallucinations often involving snakes or bugs.

Concerns about misuse and overprescription of ADHD drugs, many of them chemical cousins of amphetamines, are not new. But hope that the common neurobehavioral disorder could be effectively treated without medication was dealt a severe blow seven years ago when a landmark study of nearly 600 school-age children found that medications were the most effective treatment.

That study, funded by the National Institute of Mental Health, also found that the best outcomes, measured by parental satisfaction and some academic standards, were the result of "combination" treatment: medications that reduce hyperactivity and improve concentration, and behavior therapy to address some of the more subtle symptoms, such as difficulty with organizational and social skills.

While other non-drug treatments - play therapy, cognitive therapy, psychotherapy and special diets - have been regarded as promising, only behavioral treatment has been shown to work. But experts caution that it is an adjunct to, not a substitute for, medication.

Although ADHD specialists say they consider behavior therapy a key component of effective treatment and one that has inspired a recent resurgence of interest, many parents don't invest the time and effort necessary for it to be effective.

"There's so much lip service paid to (combined) treatments, but a lot of people just rely on medication alone," said William L. Coleman, a developmental pediatrician at the University of North Carolina who is chairman of the American Academy of Pediatrics Committee on Psychosocial Aspects of Child and Family Health. "We are a quick-fix society and we want results. There's a lot of time pressure on parents and on teachers."

A behavior therapy regimen can be developed by a pediatrician or a school psychologist or another mental health worker. Based on a structured system of rewards and consequences - such as increased or decreased TV or video game privileges - the program also includes changes in a child's environment to minimize distractions. Parents also receive training in how to give commands and ways to react when a child obeys or disobeys.

The goal is to incrementally teach children new ways of behaving by rewarding desired behavior, such as following directions, and eliminating undesired actions, such as losing homework, notes Ginny Teer, a spokeswoman for Children and Adults with Attention Deficit/Hyperactivity Disorder (CHAAD), a national advocacy group based in Landover, Md.

Experts say behavioral therapy sounds easier than it is. Parents often "have an inappropriate expectation of what medications can do," observed Washington pediatrician Patricia Quinn, who has specialized in treating ADHD for more than 25 years. "Drugs don't improve self-esteem, time management or organizational skills. But the problem is that most parents don't have enough time or energy" for behavior therapy or are inconsistent about applying it. Sometimes, Quinn said, they make the regimen too complicated by imposing too many rules.

The trick, Quinn said, is to keep things simple, especially for younger children, which enables them to succeed, thereby reinforcing the desired behavior.

McLean, Va., child psychiatrist Thomas Kobylski compares ADHD to diabetes: Medications are necessary but not sufficient for both conditions. hildren with ADHD, he said, need medication as well as the skills that behavior therapy teaches to function well at home and at school.

There is an added benefit from combination treatment, said Kobylski, who is chairman of the Washington area chapter of the American Academy of Child and Adolescent Psychiatry. Studies have found that children treated with behavior therapy can take a lower dose of medication, Kobylski said.

Behavior therapy

Behavior therapy, the only non-drug treatment for ADHD that has been proven to work, is most effective when combined with medication. It is designed to determine the factors that trigger undesired behaviors and then enforce consequences, or bestow rewards, designed to change those behaviors.

Parents are taught how to more effectively give commands to children and how to react when a child does, or does not, comply. Teachers use similar techniques in the classroom.

Behavioral therapy typically consists of the following components:

• Goals the child can achieve incrementally, such as brushing teeth without multiple reminders.

• Consistency in different situations - and with different caregivers. Rules and expectations at home and at school should not be divergent; one parent should not be more lenient in enforcing them.

• Rapid feedback and accessible rewards. Praise should swiftly follow good behavior and consequences follow bad behavior. Promising a trip to a favorite restaurant after a week of compliance is too distant a reward for a young child; a trip for ice cream after a day of good behavior may be more effective.