Does your child have difficulty staying focused, sitting still, or finishing a task? If so, he or she could be one of the three- to five-percent of school-age children who are diagnosed each year with attention deficit hyperactivity disorder (ADHD). Left untreated, ADHD can impact your child's ability to learn and make friends. The condition frequently occurs with depression and anxiety disorders, antisocial behavior, and substance abuse.
Although the jury is still out on the safety and effectiveness of various ADHD therapies, clinicians have learned a great deal since the National Institute of Mental Health launched its Multimodal Treatment Study of Children with Attention Deficit Hyperactivity Disorder (MTA) study more than a decade ago.
In that study, researchers at six university medical centers evaluated the three leading ADHD treatments in nearly 600 elementary school children, ages seven to nine. The children were randomly assigned to one of four groups: medication-only (methylphenidate); behavioral treatment-only; a combination of medication and behavioral treatment; and supportive services in communities and schools. (Behavioral treatment consisted of weekly parent training for six months, biweekly consultation provided to the child's teacher for three to four months, and an eight-week summer treatment program for the children.) The MTA study monitored the children closely for up to 14 months and then followed up one and two years later. After the 14 months of assigned treatments were completed for the original study, families were free to choose their child's treatment.
The first findings from this study, published in December 1999, indicated that long-term combination treatment or medication-only were both better in reducing ADHD symptoms than behavioral treatment-only or supportive services. These benefits lasted for up to 14 months.
Four reports that followed up on 485 children from the MTA study were published in the August 2007 issue of Journal of the American Academy of Child and Adolescent Psychiatry. These reports showed that most children treated for ADHD continued to show improvement three years after starting treatment. However, after the 14 months of controlled treatment ended, the initial advantages of medication (whether alone or in combination) over behavioral treatment-only or supportive services gradually diminished. Two years after the study ended, continuing medication treatment was no longer associated with better outcomes.
William E. Pelham, Jr., M.D., University at Buffalo Distinguished Professor of Psychology, Pediatrics, and Psychiatry and co-author of the MTA study, says that the MTA study is consistent with a large body of literature that fails to find any evidence of beneficial effects of stimulant medications on ADHD children's long-term outcomes.
A study by the Mayo Clinic, Long-Term School Outcomes for Children with Attention-Deficit/Hyperactivity Disorder, published in the Journal of Developmental and Behavioral Pediatrics in 2007, found that long-term treatment of ADHD with stimulant medication is associated with decreased rates of school absenteeism (by one day per year) and less likelihood of repeating a grade.
This study examined the effects of medical stimulants such as methylphenidate (Ritalin), maternal age, socioeconomic background, and special-education services on academic outcomes. The study looked at the medical and school records of 370 children diagnosed with ADHD at the Mayo Clinic. The children treated with stimulants typically began taking medication in elementary school and received it for an average of 30.4 months.
Dr. Pelham suggests a few limitations of the Mayo Clinic study, including the fact that the researchers reviewed records rather than conducting face-to-face examinations with children, parents, and teachers. Plus, the study location (a mostly white, middle-class county) may not be representative of the entire population. The MTA study focused on families in real-time and from a wide range of ethnicities and economic status.
So what should parents take away from these two studies?
Medication is a useful short-term adjunct for ADHD kids who are being treated with appropriate evidence-based behavioral and psycho-educational interventions when those interventions are insufficient, Dr. Pelham states. But parents should not expect long-term benefits from medication. And, if treatment begins with medication, it undermines the probability of parents and schools engaging in appropriate non-drug treatments.
Stimulants are useful for ADHD, but do not use them forever and try kids off of them-for example, during summers, recommends Isabelle Rapin, M.D., professor of neurology and pediatric neurology at Albert Einstein College of Medicine in Bronx, NY. Drugs do not cure ADD with or without hyperactivity, but they can help make kids more available to education/behavior interventions, which are key.
Dr. Pelham adds, Parents should insist that doctors hook them up with appropriate providers of evidence-based psychosocial treatments and that their insurance pays for those treatments. I'm concerned that medication is being increasingly used as the first and sole intervention of ADHD, and that parents are being told that it will help in the long run, when the evidence is very clear that it will not.