Behavioral therapies are recommended before resorting to drugs in a number of common conditions, such as ADHD in young children and chronic insomnia in adults. But practitioners have objected that there are barriers to providing behavioral therapies to large numbers of patients and that drug treatments are simply more practical.
We contacted a variety of experts in ADHD and sleep disorders via email to ask:
What barriers of this sort have you seen in your own practice?
Have you prescribed drugs as first-line treatment even while knowing that behavioral therapies might be a better choice?
What needs to be done to make behavioral therapies more widely and easily available?
The participants this week are:
Max Wiznitzer, MD, a pediatric neurologist at University Hospitals Rainbow Babies Children’s Hospital in Cleveland
Daniel J. Buysse, MD, UPMC professor, sleep medicine and professor, psychiatry and clinical and translational science at University of Pittsburgh School of Medicine
Bradley R. Berg, MD, PhD, FAAP, division director, McLane Children’s Pediatrics – Austin/Round Rock at Baylor Scott & White Health in Round Rock, Texas.
Karl Doghramji, MD, director, Sleep Disorders Center at Thomas Jefferson University Hospital and professor, Psychiatry and Human Behavior at Thomas Jefferson University in Philadelphia
David Fassler, MD, clinical professor, psychiatry at the University of Vermont College of Medicine in Burlington
Philip Gehrman, PhD, CBSM, assistant professor, Department of Psychiatry, Perelman School of Medicine at University of Pennsylvania in Philadelphia
Simon Rego, PsyD, director, CBT Training Program at Montefiore Medical Center/Albert Einstein College of Medicine in New York City
Kathleen Armstrong, PhD, NCSP, professor & director, pediatric psychology, USF Department of Pediatrics at University of South Florida in Tampa
Alex Mabe, PhD, professor and chief of psychology, Department of Psychiatry and Health Behavior at Augusta University’s Medical College of Georgia in Augusta
Access to Professionals
Wiznitzer: The major barriers are access to professionals and parental acceptance of the therapy. Access is affected by limited number of or no available professionals (psychologist, social worker, counselor, or therapist) for the needed intervention, location distance or time availability (for working families), length of waiting list, and insurance plan limitations on who to see and how many appointments to have. Parents can view therapy as too slow or difficult to implement, an excessive time commitment, too complicated and not easy to understand, or not a real medical intervention. Additional barriers include insurance limitations on therapist choices, cost of therapy, and child resistance to the intervention (challenges the “power” they have acquired in the home).
Buysse: The main barrier to behavioral therapies is inadequate access. There are far too few clinicians trained in Cognitive-Behavioral Therapy for Insomnia (CBT-I) relative to the number of patients with insomnia. Although several online, self-guided CBT-I programs are also available, most people do not know about them, and most insurance plans do not pay for them.
Berg: The biggest barriers to behavioral therapies are the lack of access as well as the time commitment involved. Many [pediatric patients] are failing school or in danger of being expelled. Behavioral therapy takes a prolonged period of time (often months to years) and students often do not have this time to turn themselves around before serious consequences ensue. We also have a reasonable lack of mental health providers who accept many of the common insurances. This makes it difficult to find behavioral therapy for patients in a timely manner. I have patients who have been waiting for several months to get in to see a mental health provider to start with behavioral therapy.
Fassler: Many young children with ADHD respond well to behavioral interventions. However, parents often have difficulty identifying and accessing such resources. In many areas, there are too few clinicians with appropriate training and expertise to provide such therapy. Even where providers exist, limited reimbursement often creates additional barriers. I fully concur with the CDC’s recommendation that health care providers and parents should work together to make sure young children with ADHD are receiving the most effective and appropriate treatment possible.
Gehrman: There are two main barriers to behavioral treatment of insomnia. First is lack of awareness, as most providers who treat patients with insomnia don’t even know it exists (although the new guidelines will help with that), nor do most patients with insomnia. Second is lack of trained providers. Most mental health or sleep medicine providers are not trained in this type of treatment.
Armstrong: Behavioral parent training using an evidenced-based intervention such as Parent Child Interaction Therapy (PCIT) is the gold standard treatment for children ages 3-7 with ADHD, and is recommended as first approach by the American Academy of Pediatrics. Effect sizes for PCIT are larger (1.43) compared with stimulant medication (0.9); parents prefer this option to medication when given the choice; results are documented to last up to 6 year. That being said, PCIT requires sufficient mental health coverage and trained providers to deliver it effectively. Medicaid does not typically cover PCIT, only medication. And parents have to commit to 10-16 weekly visits and home practice for this approach to work.
Buysse: Self-guided internet CBT-I interventions are one answer. In one of our current NIH-funded clinical trials, we are comparing internet CBT-I to a brief behavioral treatment conducted by a live therapist over the telephone or videoconferencing. These approaches are likely to reach a lot more people.
Mabe: Families are often reluctant to try behavioral therapies to address the problems with ADHD in children, because the effort is more intense than just giving the child a pill. Moreover, many parents believe that they have already tried to use behavioral approaches to the child’s problem behaviors and have concluded that ‘they don’t work.’ The research supports a different conclusion, however, on this last objection to behavioral therapies. Specifically, we are learning that the use of behavioral management and organizational strategies in children with ADHD is usually effective, and the children do get better when proper techniques are applied and everyone is patient with the process. Positive results often take more time with behavioral therapies, but the results are similar to those observed with medication. Additionally, the benefits of behavioral therapies may be broader and may even last longer.
Medication Not First-Line Option
Buysse: I always provide my patients with behavioral sleep advice, even when I also prescribe a medication. When you think about it, even taking a pill is a behavior, and requires instruction. For instance, part of a behavioral intervention for insomnia involves recommendations for what time to go to bed, what time to get out of bed — and what time to take the prescribed medications. Hypnotic medications taken at the wrong time of day can be ineffective or cause side effects.
Wiznitzer: Occasionally, parents have been resistant to any therapy implementation or have not been able to access an appropriate provider. In those circumstances, medication can be started with the parents’ understanding that this treatment can improve attention span and decrease impulsivity but will not teach the child how to behave or how to learn. When an improvement from medication is noted, a discussion about the use of behavioral therapy can then lead to acceptance of combined intervention. On must remember that there are some children for whom medication is necessary from the beginning.
Gehrman: As a psychologist I cannot prescribe drugs so this was never an option. Plus, I have been trained in behavioral treatment since very early in my professional development so this has always been my main focus.
Berg: Although I always recommended behavioral therapies as well, I often do resort to medications for the reasons listed above.
Rego: Educate consumers about the impressive, research-backed benefits of cognitive behavioral therapy (CBT), not just for insomnia, but also for anxiety, depression, and a host of other psychological disorders, by publishing articles about it and discussing it in reputable mainstream media outlets like this one, increase training in CBT by adding courses into graduate programs for mental health workers and by offering workshops and supervision in CBT to those already in the field, and increase access to CBT by modifying the ways in which the treatment can be delivered — such as through websites and apps — while being sure to study these modified versions so we can verify that they are equally effective as the original treatment.
Berg: The biggest things that need to be done to make behavioral therapy more accepted and available is early diagnosis as well as increasing access. Often we see students in the office who have been struggling for 2 or 3 years before there brought to medical attention.
Gehrman: Patients and providers need to be educated about this treatment option. There also needs to be larger efforts to train providers to deliver this treatment.
Doghramji: In the long run, we need a greater number of trained CBT-I therapists who can provide treatment at an affordable cost to a wide variety of patients. Providing training to paraprofessional staff in clinical settings is important. Other practical measures include the recent development of group treatment strategies, therapies involving a diminished number of sessions, and utilization of online resources. The emergence of telemedicine has also begun to make CBT-I a more readily available treatment resource.
Wiznitzer: Availability of well trained and knowledgeable therapists for this population, making sure that they are identified to healthcare providers, educators, day care providers, and families (so they can be accessed), make sure that cost is not an impediment, educate parents that behavioral therapies are proven treatments when appropriately implemented (i.e., be an informed consumer) and utilize technologies, such as videoconferencing and the Internet, as vehicles for parent education and therapist access.
Armstrong: More comprehensive and better health insurance for mental health; more providers with training and expertise to provide evidence-based interventions.
LAST UPDATED 06.01.2016