Research on Treatment for ADHD

Children with attention deficit hyperactivity disorder (ADHD), the most common of the psychiatric disorders that appear in childhood, are often the subject of great concern on the part of parents and teachers. Children with ADHD are unable to stay focused on a task, cannot sit still, act without thinking, and rarely finish anything. If untreated, the disorder can have long-term effects on a child's ability to make friends or do well at school or in other activities. Over time, children with ADHD may develop depression, lack of self-esteem, and other emotional problems.

Experts estimate that ADHD affects 3 to 5 percent of school-age children and two to three times as many boys as girls. Children with untreated ADHD have higher than normal rates of injury. ADHD frequently co-occurs with other problems, such as depression and anxiety disorders, conduct disorder, drug abuse, or antisocial behavior.

Although ADHD is relatively common, our knowledge of the problem is incomplete. Current ADHD treatment includes a mix of approaches, such as drug therapy, counseling, supportive services in schools and communities, and various combinations of the three. The medical literature offers many studies carried out over brief treatment periods (3 months or less), but a pressing question remains: what is the best kind of help we can offer children with ADHD over a longer term?

To answer this question, NIMH is sponsoring an ongoing, multisite, cooperative agreement treatment study of children with ADHD entitled The Multimodal Treatment Study of Children with Attention Deficit Hyperactivity Disorder. The first findings from this study, which were published in December 1999, provide important guidance for physicians and parents of children with ADHD and are discussed below. Ongoing follow-up reports will be published, with an additional 10-15 papers expected to be released in calendar year 2000.

Questions and Answers

Q. What is the Multimodal Treatment Study of Children with ADHD?

A. The Multimodal Treatment Study of Children with ADHD�"MTA" for short�brought together 18 nationally recognized authorities in ADHD at 6 different university medical centers and hospitals to evaluate the leading treatments for ADHD, including various forms of behavior therapy and medications. The study has included nearly 600 elementary school children, ages 7-9, randomly assigned to one of four treatment modes: (1) medication alone; (2) psychosocial/behavioral treatment alone; (3) a combination of both; or (4) routine community care.

Q. Why is this study important?

A. ADHD is a major public health problem of great interest to many parents, teachers, and health care providers. Up-to-date information concerning the long-term safety and comparative effectiveness of its treatments is urgently needed. While previous studies have examined the safety and compared the effectiveness of the two major forms of treatment, medication and behavior therapy, these studies generally have been limited to periods up to 4 months. The MTA study demonstrates for the first time the safety and relative effectiveness of these two treatments (including a behavioral therapy-only group), alone and in combination, for a time period up to 14 months, and compares these treatments to routine community care. The children involved in the study will be tracked into adolescence to document and evaluate long-term outcomes.

Q. What are the major findings of this study so far?

A. The MTA results published in December 1999 indicate that long-term combination treatments as well as medication-management alone are both significantly superior to intensive behavioral treatments and routine community treatments in reducing ADHD symptoms. The study also shows that these differential benefits extend as long as 14 months. In other areas of functioning (specifically anxiety symptoms, academic performance, oppositionality, parent-child relations, and social skills), the combined treatment approach was consistently superior to routine community care, whereas the single treatments (medication-only or behavioral treatment only) were not. In addition to the advantages provided by the combined treatment for several outcomes, this form of treatment allowed children to be successfully treated over the course of the study with somewhat lower doses of medication, compared to the medication-only group. These same findings were replicated across all six research sites, despite substantial differences among sites in their samples' sociodemographic characteristics. Therefore, the study's overall results appear to be applicable and generalizable to a wide range of children and families in need of treatment services for ADHD.

Q. Given the effectiveness of medication management, what is the role and need for behavioral therapy?

A. As noted in the NIH ADHD Consensus Conference in November 1998, several decades of research have amply demonstrated that behavioral therapies are quite effective. What the MTA study has demonstrated is that on average, carefully monitored medication management with monthly follow-up is more effective than intensive behavioral treatment for ADHD symptoms, for periods lasting as long as 14 months. All children tended to improve over the course of the study, but they differed in the relative amount of improvement, with the carefully done medication management approaches generally showing the greatest improvement. Nonetheless, children's responses varied enormously, and some children clearly did very well in each of the treatment groups. For some outcomes that are important in the daily functioning of these children (e.g., academic performance, familial relations), the combination of behavioral therapy and medication was necessary to produce improvements better than community care. Of note, families and teachers reported somewhat higher levels of consumer satisfaction for those treatments that included the behavioral therapy components. Therefore, medication alone is not necessarily the best treatment for every child, and families often need to pursue other treatments, either alone or in combination with medication.

Q. Which treatment is right for my child?

A. This is a critical question that must be answered by each family in consultation with their health care professional. For children with ADHD, no single treatment is the answer for every child; a number of factors appear to be involved in determining which treatments are best for which children. For example, even if a particular treatment might be effective in a given instance, the child may have unacceptable side effects or other life circumstances that might prevent that particular treatment from being used. Furthermore, findings indicate that children with other accompanying problems, such as co-occurring anxiety or high levels of family stressors, may do best with approaches that combine both treatment components, (i.e., medication management and intensive behavioral therapy). In developing suitable treatments for ADHD, each child's needs, personal and medical history, research findings, and other relevant factors need to be carefully considered.

Q. Why do many social skills improve with medication?

A. This question highlights one of the surprise findings of the study: although it has long been generally assumed that the development of new abilities in children with ADHD (e.g., social skills, enhanced cooperation with parents) often requires the explicit teaching of such skills, the MTA study findings suggest that many children can often acquire these abilities when given the opportunity. Children treated with effective medication management (either alone or in combination with intensive behavioral therapy) manifested substantially greater improvements in social skills and peer relations than children in the community comparison group after 14 months. This important finding indicates that symptoms of ADHD may interfere with their learning of specific social skills. It appears that medication management may benefit many children in areas not previously well known to be salient medication targets, in part by diminishing symptoms that had previously interfered with the child's social development.

Q. Why were the MTA medication treatments more effective than community treatments that also usually included medication?

A. There were substantial differences between the study-provided medication treatments and those provided in the community, differences mostly related to the quality and intensity of the medication management treatment. During the first month of treatment, special care was taken to find an optimal dose of medication for each child receiving the MTA medication treatment. After this period, these children were seen monthly for one-half hour at each visit. During the treatment visits, the MTA prescribing therapist spoke with the parent, met with the child, and sought to determine any concerns that the family might have regarding the medication or the child's ADHD-related difficulties. If the child was experiencing any difficulties, the MTA physician was encouraged to consider adjustments in the child's medication (rather than taking a "wait and see" approach). The goal was always to obtain such substantial benefit that there was "no room for improvement" compared with the functioning of children not suffering from ADHD. Close supervision also fostered early detection and response to any problematic side effects from medication, a process that may have facilitated efforts to help children remain on effective treatment. In addition, the MTA physicians sought input from the teacher on a monthly basis, and used this information to make any necessary adjustments in the child's treatment. While the physicians in the MTA medication-only group did not provide behavioral therapy, they did advise the parents when necessary concerning any problems the child may have been experiencing, and provided reading materials and additional information as requested. Physicians delivering the MTA medication treatments generally used 3 doses per day and somewhat higher doses of stimulant medications. In comparison, the community-treatment physician generally saw the children face-to-face only 1-2 times per year, and for shorter periods of time each visit. Furthermore, they did not have any interaction with the teachers, and prescribed lower doses and twice-daily stimulant medication.

Q. How were children selected for this study?

A. In all instances, the child's parents contacted the investigators to learn more about the study, after first hearing about it through local pediatricians, other health care providers, elementary school teachers, or radio/newspaper announcements. Children and parents were then carefully interviewed to learn more about the nature of the child's symptoms, and rule out the presence of other conditions or factors that may have given rise to the child's difficulties. In addition, extensive historical information was gathered and diagnostic interviews were conducted to establish whether or not the child exhibited the long-standing pattern of symptoms characteristic of ADHD across home, school, and peer settings. If children met full criteria for ADHD and study entry (and many did not), informed parental consent with child assent and school permission were received; the children and families then were eligible for study entry and randomization. Children who had behavior problems but not ADHD were not eligible for study participation.

Q. Where is this study taking place?

A. Research sites include:

New York State Psychiatric Institute at Columbia University, New York, N.Y.
Mount Sinai Medical Center, New York, N.Y.
Duke University Medical Center, Durham, N.C.
University of Pittsburgh, Pittsburgh, PA.
Long Island Jewish Medical Center, New Hyde Park, N.Y.
Montreal Children's Hospital, Montreal, Canada
University of California at Berkeley, CA.
University of California at Irvine, CA.