by Joye C. Anestis, M.S.
Tracy Witte's contribution last week about attention-deficit/hyperactivity disorder (ADHD) incited a flurry of PBB comments. Today, I wanted to continue the conversation on ADHD by focusing on frontline treatments for the disorder (if you are interested in learning about the diagnosis of AD/HD, see Tracy's article).
In her article, Tracy mentioned the landmark 1999 study produced by the Multimodal Treatment Study of Children with ADHD (MTA). This study assigned children to one of 4 treatment conditions: medication management, behavioral treatment, combined treatment (medication + behavioral treatment), or routine community care (it should be noted that all of these children met DSM-IV criteria for ADHD, combined type). The authors found equivalent results for medication alone and for medication combined with behavioral treatment (in this case, Barkley's parent training
, Pelham's summer treatment program, and school-based treatment). There were a variety of other findings within this study, including greatest parent satisfaction in combined and behavioral treatment groups, greatest improvement in non-ADHD domains (e.g., oppositional/aggressive behavior, internalizing disorders) for the combined group, and a significant trend for the combined group to require lower doses of medication. This 1999 study reported results after 14-months of treatment, and there have been several other follow-up studies published. Recently, an 8-year follow-up was released by the Journal of the American Academy of Child and Adolescent Psychiatry. The authors, Molina and colleagues, found an attenuation of treatment effects at the 8-year follow-up, when intensity of the treatment had been relaxed. In other words, while the initial improvements were maintained, none of the 4 original groups were significantly different from each other. Additionally, when compared to a group of randomly selected peers, the MTA subjects were functioning more poorly than their non-MTA peers on a variety of indices.
This updated MTA study raises some interesting questions about the nature and quality of ADHD treatment. One of the conclusions drawn by the authors regards the quality of care received by the children once the MTA treatment ended. The MTA medication treatment protocol, for example, involved intensive care by physicians and utilized a carefully constructed titration schedule to determine the optimal medication and dose for each child. This is far above and beyond standard care received by the children in the community. A potential implication of this study, then, is that without careful monitoring, medication treatments for ADHD are not as successful as they could be. On the other hand, several other studies have failed to find long-term gains for medication treatment, and some have reported deleterious effects of long-term medication management. (e.g., stunted growth) - so it's not surprising that this study also found lack of support for medication in long-term. In contrast to medication treatments, behavioral treatments (e.g., Barkley's parent training) for ADHD have not been shown to have negative consequences, but these treatments are often ignored or parents are unaware of them. Behavioral treatments do not have the short-term, more immediate gain found in medications. Instead, their benefits are evidenced over time. But again, the new 8-year follow-up data indicates that, without long-term maintenance or booster sessions, the effects begin to attenuate. The bottom line of this line of research is that, while we are very good at treating ADHD in the short-term, we still have work to do in maintaining treatment gains long-term.
What do you think about these new findings? What questions do they raise for you? Any ideas on how to improve the standard quality of care for these children?
Joye Anestis is a doctoral candidate in clinical psychology at Florida State University.
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