The Best Treatments For ADHD Kids, Based on Evidence

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0:30Today, Mike and I are going to talk about what the research shows on effective ADHD treatments. And you're going to want to listen to this episode because we're going to cover things that most parents and even most professionals don't know. So stay tuned. Welcome to the ADHD Parenting Podcast with Mike McLeod of Grow Now ADHD and Ryan Wechselblatt of ADHD Dude. Learn about parenting kids with ADHD from a licensed clinical social worker and speech-language pathologist who specializes in ADHD.

1:00No fluffy parenting advice, only practical information that will equip you to help your child with ADHD effectively. Today, we're going to talk about something that creates a lot of confusion for parents. You're told to get your child into therapy for their ADHD. Schools will say it. Pediatricians will say it. Other parents will say it. And social media is pushing this narrative nonstop. The problem is that when you pull the research,

1:30when you open the actual treatment guidelines, when you look at decades of outcome data, traditional therapy is not what the evidence says is effective for ADHD. We have to remember, this is not about criticizing therapy. It's about giving you clarity so you can make decisions based on science and not assumptions. So what we're going to do today, we're going to point out common misinformation about therapy or counseling or skills groups

2:01being recommended as first-line approaches for kids with ADHD. One of the things that I want to mention, I am a licensed mental health professional. I'm a licensed clinical social worker. So I am, both myself and Mike, are in no way anti-therapy. You know, we believe that therapists can serve in a supportive role, but we just want to provide families with clarity about what the research actually shows about not only effective treatments, but why the recommended treatments are recommended. So we're going to get started with that.

2:31Mike, why don't we talk about what the major guidelines really recommend? Yeah, overall, I would say this is a great place to start because this information really surprises most parents that we talk to. The American Academy of Pediatrics 2019 ADHD clinical practice guidelines are actually quite clear, and they did that intentionally so there was little to no confusion because of how much information and pseudoscience is out there. For children ages four to five, the first line of treatment is evidence-based parent training

3:06in that behavior management for ADHD and executive dysfunction, not weekly therapy for the child. For ages six to 18, the guideline recommends medication as a first-line treatment when applicable, of course, often combined with behavioral interventions that involve both the parents and the schools. And that's the key here, is that the parents are involved and the schools are involved, which is not typical for most talk therapy and counseling.

3:41So again, not weekly talk therapy as a recommendation for 18 and below. Mike, one thing I do want to clarify for families is that for ages four to five, while evidence-based parent training behavior management is the first-line recommendation, medication can be used as well. And they specifically state that methylphenidate can be used. Now, I have seen other meds be used in this age range as well, but I just want to clarify that. The other thing I want to clarify for everybody is the American Academy of Pediatrics

4:13use this term parent training or parent behavior training or parent training and behavior management. They're interchangeable terms, and they are extremely confusing for people. And what I have heard is that the American Academy of Pediatrics has left this vague on purpose, which I don't think was a good idea because it's really confusing for people. And I think, Mike, a lot of the times when people hear, you know, behavior, you know, parent training and behavior management, or they hear behavior therapy, they think that that means, you know, a mobile therapist working with the child directly, you know,

4:46and that's not what it's for. So I just want to clarify that. So I'm going to talk about the Society of Child and Adolescent Psychiatry, also known as the American Academy of Child and Adolescent Psychiatry. Their practice parameters mirror those of the American Academy of Pediatrics, and those are the core treatments are medication and behavioral parent management training, plus classroom modifications that we would find with a 504 plan or an IEP. There is no recommendation that any type of insight-oriented therapy or non-directive child therapy effectively treats ADHD itself.

5:20And I want to be clear for everybody, these are the most current guidelines there are. So when parents read the actual guidelines from the AAP and the Society of Clinical Child and Adolescent Psychology, they're often surprised. Sometimes they get argumentative about it, as do clinicians. But the bottom line is weekly therapy for the child is not a recommended first-line ADHD treatment. So we're going to move on, and we're going to talk a little bit about Dr. Russell Barkley's research. So for those of you unfamiliar, Dr. Barkley, who is now retired,

5:53is probably the foremost expert on ADHD in the world. He's written plenty of books, has conducted a tremendous amount of research. So let's talk about what he has found in his research over his long career. Exactly. And one of the most important things about Dr. Russell Barkley is nobody besides him has worked with more individuals with ADHD across their entire lifespan. So he worked with ADHD students for a very, very long time, and he was able to see them from very young until adulthood.

6:25So his work is really second to none. His work has influenced ADHD research more than almost anyone else, and the findings are quite consistent. The psychosocial treatments with the strongest evidence are parent behavior training, which we talk about, of course, classroom behavior modification, and specific academic interventions when needed. Therapy sessions that focus on talking through feelings is not a recommendation.

6:56So Ryan kind of hinted at it earlier that, yeah, a lot of parents will hear us say that therapy and counseling are not going to assist with the ADHD behaviors and the executive dysfunction, and people get very emotional about that because therapy and counseling is something that feels good, and this concept of get your kid in therapy to talk through their feelings and talk through their emotions is something that really talks to the heartstrings of many, many parents and helps them to feel good.

7:27But also on the flip side of things, it tends to be the opposite of parent behavior training. So in many ways, it sort of becomes like checking that box of, oh, I got my son, my daughter in therapy. They have someone to talk to. I, as the parent, don't have to do the hard things. He can do that through the therapist, and that's simply not going to help. So, you know, you've heard Ryan and I say this before because it's Dr. Barclay's core point. ADHD is a disorder of performance, not a disorder of knowing what to do.

8:02So it's not a disorder of knowledge. It's a disorder of showing what you know and performance, performing in the natural environment in real time. So if a treatment does not change a performance condition in a real-time setting, that's not going to change ADHD symptoms. So sending your child to a therapist's office to go talk to them for an hour or logging in on a Zoom to talk to a therapist for an hour and talk through their feelings and have a conversation

8:33and everything being very talk therapy-based, as soon as they leave that therapist's office, as soon as they sign off of that Zoom, they're going to go right back to their impulses. They're going to go right back to the inability to stop and think and aim their behavior towards the future, and they're going to be at the mercy of their impulses and their dysregulation, which is what you saw before the therapy session. And that's exactly why parent training works, and that's why school-based behavior plans work,

9:04because they change the environment, the reinforcement, the structure, and the expectations. Talk therapy does not. Mike, I think we also need to give a shout-out to Dr. Barkley, because he did use a clip from the ADHD Parenting Podcast in one of his YouTube videos. So thank you to Dr. Barkley for that. All right, so we're going to move on, and we're going to talk about what the research shows about cognitive behavior therapy, CBT, dialectical behavior therapy, DBT, and play therapy. So I want to mention I have training in CBT from the Beck Institute

9:37where cognitive behavior therapy was invented. In fact, when I did my training, Dr. Beck, who invented CBT, came in and did a role-playing in the class, which was great. But after doing that training, you know, I walked away, and I said to myself, you know what? This is not going to really be helpful for the kids I work with, and when we go through the reasons why, it'll make sense. Okay, so here's what the research shows about CBT. So for children under 12, there is no strong evidence that CBT improves core ADHD symptoms. Studies also show that CBT does not outperform medication

10:11or parent training. For adolescents, and typically the research I've seen, Mike, is that this is for older teens, that there's mixed findings, that CBT can help improve organizational skills or reduce internalizing symptoms, but still not a primary treatment for core ADHD symptoms. So the bottom line is CBT can be helpful for older teens and adults, but for younger kids, CBT is not an evidence-based treatment for core ADHD symptoms. And there's one thing I want to add on here.

10:41And I talked about this with Dr. Ellie Leibovitz, who is a creator of SPACE, which is an evidence-based intervention for anxiety. A really important point that Dr. Leibovitz brought up when I interviewed him, and you can see it on my YouTube channel, is that for somebody to participate in CBT and for it to be effective, they have to be motivated. So even if you have an older teen or a young adult who's going to CBT, if they're just going through the motions and they're not motivated, it's not going to help them. CBT requires motivation.

11:12It also requires strong internal dialogue, because a lot of CBT involves reframing your thoughts. And Mike can speak to why that is really not, you know, a great intervention for kids with ADHD, because, well, I'll let Mike explain it. Yeah, of course. So that whole aspect of internal voice, that internal voice is the foundation of executive functioning. ADHD is a disorder of executive functioning, and executive functioning at its foundation is both nonverbal and verbal working memory.

11:44Nonverbal working memory, the visual imagery system of the brain, making mental movies of the past, the present, and the future. And then verbal working memory is the self-directed talk system, the ability to have self-stated intentions and talk to your brain to work towards the future and plan, prioritize, problem solve, and delay gratification. So really that ability to have that internal dialogue is the foundation of executive functioning, which is the core deficit of ADHD, which is one of the foundational prerequisite skills needed

12:16to be successful at CBT. So, you know, as we're breaking down here why CBT is not a recommended treatment for ADHD kids, that's really the number one reason right there is the lack of the internal voice. All right, Mike, why don't you talk about the research about DBT dialectical behavior therapy? Yeah, and right now on social media, there's a lot of hype around DBT and these emotional regulation groups being a treatment for ADHD. But once again, once we look at the research,

12:46the science, the data, it does not support DBT as a treatment for ADHD symptoms. So many of the studies that were done on DBT were not designed to treat ADHD itself and specific on the ADHD individual. You may see improvement for kids who struggle with more severe things like known self-harm or very extreme dysregulation, but that's not a specific ADHD treatment.

13:18Mike, this is very timely because I received an email a few days ago from a mom who said, you know, my daughter has done CBT and DBT and she refuses to learn and she refuses to use any of the skills she's learned in this in CBT or the DBT group. And I said to her, it's not that she's refusing to use the skills she learned, it's that she can't apply them in the moment because ADHD, as we know, is a condition of inconsistent performance. So as Dr. Barclay says,

13:48it's not knowing what to do, it's applying what you know. And I explained to her, so it's not a matter of her refusing. That's why that seems to be not effective. So, all right, let's move on and let's talk about play therapy and what the research shows about that. So, number one, the evidence is extremely limited on play therapy. It's primarily been small exploratory studies, often under 15 kids, and they show inconsistent results. And play therapy is not recognized by the American Academy of Pediatrics

14:20or the American Academy of Child and Adolescent Psychiatry as a treatment for ADHD. So, Mike, I have to tell you, I am in a therapist group in my state here, a Facebook group, and, you know, people will post almost every day, you know, looking for a therapist to work with kids with ADHD. And at this point, Mike, I've stopped even responding to them because when I explain to them the research, they get angry. And I've been ganged up on when I simply state the research. And whenever, you know, whenever somebody says this, you know, some, you know, 50 play therapists respond with,

14:51I can do it. I work on emotional regulation and I so badly want to say, and what exactly do you think you're going to do when the research shows this is not effective? But I don't because it is what it is. So, so much to the disappointment of many parents, play therapy, not an evidence-based recommended treatment for kids with ADHD. And Mike, I think both of us have seen in so many evaluations, play therapy being recommended to families. Am I correct that you've seen that tons of times all through? So, absolutely.

15:21Basically, every single thing we're discussing in this episode, I've seen on very expensive and thorough evaluations. And it's quite upsetting to see. You know, Ryan and I have spoke on numerous episodes of this podcast that, you know, one of the saddest and most heartbreaking things about, you know, that we've witnessed in this field of ADHD are when parents first reach out to Ryan for his membership site, first reach out to me for Grow Now. So many of them have just been through the ringer of ineffective therapies.

15:53They've wasted so much time, so much money, so much energy, and they're just so skeptical, they're so burnt out, and they're so tired because they followed the recommendations that were on a very expensive evaluation or they went with something that a licensed professional told them to do that was simply just an outdated recommendation. And that is a very, very sad thing to see. And just to further back of what Ryan said earlier, it's just so fascinating how people's emotions

16:24are so tied to these things like play therapy and counseling and talk therapy and CBT. When Ryan and I try to express the facts that these things are not going to assist with ADHD, people get very emotional and get very, very defensive. I talk all the time about screens and how they're dangerous and people will use all these cognitive distortions of, oh, but they're social, they keep kids safe and all of these different things. Yeah, it's really the exact same thing

16:55with all of these different things as well. And parents will start to say, oh, yeah, he has ADHD, but I have him in talk therapy because he's also anxious. I have him in CBT because he also displays all these different behaviors. Or I have him in play therapy because he has no friends and he has to learn how to be social. And they're basically finding a different therapy, a different approach, a different specialist for each unique symptom.

17:26And they're going through all of these cognitive distortions as to why they need to have their kid in as many different treatments as possible, regardless of what the science is actually saying. So, Ryan, what do you tell parents when they come to you and say, yeah, my ADHD child has ADHD, sure, but I have him in talk therapy because he also shows some anxiety towards school or social situations? Yeah. Well, I hear that constantly and I just tell them this is what the research shows.

17:56And this is really consistent with my experience of what I've heard from hundreds, if not thousands, of families over the years. So, you know, and I tell people, this is not about my opinion. This is about what the research shows. And again, you know, from being, having the privilege of speaking with so many families, you know, Mike, one of the things I do want to address with this is I see all the time in Facebook ADHD parent groups, you know, parents saying things like, oh, my child's in therapy and it definitely helped. And I want to address why that is. Number one, I think, Mike, there's, you know, the placebo effect

18:27that, you know, when a parent feels I put my child into therapy and therefore things are feeling better, you know, because they feel better that they're being proactive and that's fine that they feel better. The other thing, Mike, I think with this is that a lot of parents, you know, particularly who make decisions about therapy or treatment for ADHD, they find that talking helps them. So I think for a lot of parents, it's almost out of their comprehension why this might not be effective for their child when it makes them feel better,

18:58you know. So I just wanted to mention that because again, I mean, this is something I think we both deal with pretty much on a weekly basis, I would say. Exactly. And at the end of the day, it's about strengthening executive functions, which are experience-based like we're going to talk about. So, you know, yes, with ADHD typically comes various other things that, you know, need assistance. But when you strengthen executive functions, you decrease anxiety. When you strengthen executive functions, you're also assisting

19:28in all areas of life. Executive functions are the greatest predictor of success for human beings. Your child does not need to be in one specific treatment based on every single symptom you see. So, Mike, why don't we talk about why, you know, office-based talk therapy of any kind doesn't generalize outside of the therapy office? Okay, and let's talk about it from an executive function perspective. Exactly. So parents will tell me every single day that their child's therapist

19:59says they taught them strategies, but nothing is changing at home. And I see this all the time because the building that our office is in has several other therapists in it. And I'll see the therapist walk out with the child, the parents sitting out in the hallway, and I'll hear the therapist say, oh, he or she was great today. What a great session. He was so engaged, whatever. See you next week. Goodbye. And it's right there. Very little parent training, and it's all about how great the kid was in that very controlled setting, probably playing Legos or doing puzzles

20:29or playing games and just talking through things. And there's a reason that nothing is changing at home. It's because executive functions are experience-based, not something that talking is going to help. ADHD is all about working memory, nonverbal visual imagery, verbal self-directed talk, inhibition, the ability to stop and think, emotional regulation in the moment towards triggers of expectations

21:01and non-preferred tasks, having to shift from preferred tasks to non-preferred tasks, the ability to manage your time, and begin things that don't offer instant gratification. So please tell me how talking to a therapist, just basic talk therapy, is going to assist with any of those things. It is not. They're not being taught strategies that are going to stick and be used in real time in the home. There's a reason

21:31why nothing is changing at home, because parent training is not the foundation of the program they're in. Mike, you know, when you were talking about this, one thing that came to mind is how many parents have said to me, you know, the therapist tells me my child understood what I taught them about, like, coping skills, you know, or calming down, whatever. And, you know, and then they're surprised at, like, well, because the kid explained it to the therapist that it couldn't be applied in real life. And one of the things we have to keep in mind, you know, in regards to what Mike is saying is that,

22:02you know, additionally, therapy office don't have the triggers, the distractions, the real consequences, or the real routines of home and school, and also don't have the stimulation of, you know, whatever being around your peers and so on. They don't have the parents there. That's the biggest thing. The parents are the biggest trigger with ADHD and the parents are not there. It's the therapist. It's a neutral person. Right. So the reason why, you know, they are not learning, these skills are not being generalized outside of the therapy room is because, as Mike said,

22:32it's a controlled environment and ADHD is a condition of performance, not a condition of knowing what to do or not to do. Okay. So bottom line is you can't talk a child into better executive functioning. You can't apply their executive functioning to, you know, therapy, techniques or strategies and then expect it to, you know, happen in the real world. It's just not realistic. So, Mike, this next one is going to be hard for parents and some clinicians to hear. Okay. But we need to talk about it. So, as we know, kids with ADHD

23:02already have higher rates of rumination. Their brain gets stuck on things. They have difficulty with cognitive flexibility of letting things go. They tend to perseverate on things. They often have more negative, you know, self-perception of themselves. Their mind tends to wander more. No surprise to anybody. More perceived failure, but also they tend to have what's called positive illusory bias when they sometimes think they're better at something than they are, even though there's evidence showing otherwise. But one of the things we want you to hear is that there's research showing that rumination

23:34mediates anxiety and depression in ADHD. So, it can actually make things worse. And one of the things, Mike, I teach in my parent training courses is that when your child makes self-defeating comments, we don't constantly talk about it because the more energy and validity you give to self-defeating comments that are often just set out of frustration, the more you're validating them and the more you're causing your child to think, oh, maybe I am really bad at this because look how much attention my parents are giving to it.

24:04So, if, you know, therapy sessions, besides the fact that they're not recommended, you know, because they're not evidence-based, if they repeatedly focus on mistakes and poor choices and processing feelings and analyzing behavior, you can actually increase anxiety, increase rumination, increase shame, avoidance, and even oppositional behavior. And again, this is not because therapists are bad, it's because the treatment model doesn't match the ADHD brain. Yeah, and I Ryan, I'm sure you agree with me

24:35on this, I've seen this happen. I've spoken to many parents that have gone towards therapy because maybe they had more in-person options or maybe it was cheaper or through insurance, whatever it may be, and the parents, you know, started a talk therapy counseling based program and things actually got worse because of this rumination, increase of anxiety, sometimes the therapist and the parent aren't on the same page and the therapist can kind of, you know,

25:05empower the child to kind of have more of a voice and argue more and negotiate more and it's not working and it actually causes the parent to lose even more of their parental authority, which is the last thing you want with an ADHD child or teen. Mike, when I started, you know, my social media, my ADHD social media and I would talk about this information, I cannot tell you how many parents would get argumentative and say, you're wrong about that, therapy helped my child, you know, and so on and I want to

25:36talk for a minute about why parents struggle with this information and why, you know, they don't necessarily want to hear that therapy isn't the right fit for ADHD. So, as we know, you know, most parents of kids with ADHD are overwhelmed, they want to take action, they want to feel like they're being proactive in doing something, which is great. Therapy feels familiar and as I said, most parents who make decisions about treatment, talking about things feels better to them or they've been in therapy and they found it helpful. The other thing, Mike, and I can say this as a former school social worker, like I used to sit in meetings all the

26:07time, you know, in child study team meetings, which is like, you know, the school psychologist, social worker and so on and the entire team for every single kid with ADHD would push counseling on the parents and it would drive me crazy because I had to play stupid and sit there and say nothing, you know, because I couldn't, you know, contradict the people I was working with. You know, I think we know a lot of people have guilt about medication and as you said, you know, when people invest thousands of dollars in all this time and money and therapy and want it to work, you know, it's understandable

26:37that they feel like if somebody comes and tells them, yeah, this is not what's recommended, that they're going to get defensive about that. I get that. And the last thing, Mike, you know, I can't tell you how many times parents have said to me, well, my, you know, my son or daughter likes going to the therapist and I say, that's great. If they like going to the therapist, you're not paying the therapist to hang out with them and play Connect 4, right? You're going there to help solve a problem. So the fact that your child enjoys seeing a therapist, you know, and people tend to assume that enjoyment equals effectiveness

27:09and it doesn't. And I've seen that so many times. Yes. It's not about paying for an adult friend basically or a hangout and that's what so much of it ends up being. And if we can just be totally honest for a second, look, ADHD is hereditary. So many of the parents have ADHD themselves. So there is this very strong desire for instant gratification, instant success, and not wanting to have to do hard things. There isn't an ADHD parent

27:40in the world that wishes they couldn't wave a magic wand and overnight have the fights go away, the complaining go away, the dysregulation, the screen addictions, and have these things just go away. And it's, you know, it's sort of that service mindset where, you know, let me hire this person to do the hard things for me. So I don't have to step into my parental authority. I don't have to get my child mad at me. I don't have to be the bad guy. I don't have to ruin this relationship,

28:10all of those parental fears. So let me get this therapist to try to convince them to do non-screen-based tasks, to be nicer to me. To be nicer to their sibling, to try more at school. Well, at the end of the day, your child's ADHD is not like, you know, getting your house cleaned or getting your lawn mowed. You know, you can't just delegate that onto another professional. Parent training is the number one recommendation for a reason. And it's, you know, when parents contact me, it's the same question every single time is, how long until we see progress?

28:41How long until we see progress? And my answer is, and always will be, I haven't met your kid yet. I'm not answering that question. I, it's like, and if I were to answer that, that would be a massive, unethical red flag. And this whole service mindset of just being able to push everything onto a therapist, check that box, they're in therapy, they're talking to someone, I don't have to do anything, this person will take care of it. It's just, it's delusional. So look, here's the bottom line for anybody listening to this.

29:12If you send your child to therapy, you didn't do something wrong. We want to be really clear about that. You were directed to the wrong tools for the wrong problem. That's the bottom line, okay? Yeah. And there are, there are millions of families that were given this recommendation and followed it. So every single parent out there that is maybe feeling a little bit of guilt for getting their kid in therapy or whatever it may be, you literally were just doing what you thought was best based on the information you had. So you should have zero guilt. Absolutely. All right, Mike, why don't we talk quickly about why ADHD,

29:42you know, as a performance disorder and time blindness makes it difficult again for kids to implement, you know, what they've learned in therapy or even like, you know, in coaching with, you know, maybe a coach who doesn't understand this part we're talking about, you know, in terms of having a time horizon and everything. And this all goes back to why talk therapy, counseling, talking about your feelings is not going to strengthen executive functions because ADHD is a performance disorder. It isn't about knowing what to do.

30:14They know what to do. They most likely have a pretty strong IQ. It's not about, it is about the inability to perform consistently due to time blindness and the limited time horizon, which is all about how far into the future can you see? Can you visualize? Can you plan ahead? Can you work towards that future based on the number of minutes, hours, days, however long it may be into the future you can see,

30:44you can feel so you can better plan, prioritize, problem solve, and delay gratification. If you have a weakened time horizon and time blindness, it will basically make that individual feel that tasks are not urgent, that future consequences are too abstract