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TREATMENT OF ADHD—SOME GOOD NEWS, SOME BAD
The benefits of intensive medication management for attention-deficit/ hyperactivity disorder (ADHD) extend beyond the intensive treatment phase. Findings reported in the April Pediatrics indicate that the benefits of medication management continue for 10 months after therapy conclusion, although only in symptom domains, and then diminish over time.
HEAD-TO-HEAD COMPARISON OF TREATMENT MODALITIES COMPARED
In the Multimodal Treatment Study of ADHD (MTA), the effects of four approaches—medication management, behavior modification therapy, a combination of medication management and behavior modification therapy, and routine community care—in the treatment of ADHD were observed to differ at 14-month assessment. The combination therapy, medication management, behavior modification, and community care groups differed significantly in mean medication dose, with methylphenidate equivalents of 30.4, 37.5, 25.7, and 24.0 mg/day, respectively. The investigative team believes their findings support the superiority of the MTA medication management strategy (combination therapy or medication management alone) over behavior modification therapy and community comparison. Combination therapy showed modest additional benefits over medication management alone. “Here we evaluate the persistence of these beneficial effects 10 months beyond the 14 months of intensive intervention,” the investigators said of their study objective.
SIGNIFICANT DIFFERENCES
The six-site study was designed as a randomized clinical trial comparing four well-established and widespread treatment approaches for children with ADHD. Of the 579 children age 7 to 9.9 who were enrolled in the study, 540 (93%) participated in the first follow-up 10 months after the end of treatment. The researchers used mixed-effects regression models to explore possible persisting effects of the MTA medication strategy, the incremental benefits of combination over medication management alone, and the possible superiority of behavior modification therapy over community comparison on five effectiveness and four service-use domains.
“At the end of the 14-month treatment phase, we found that all four groups had sizeable improvement over time,” the team reported, although there were significant differences among groups in the rate of improvement in some areas. The MTA medication strategy showed persisting significant superiority over behavior modification therapy and community comparison for ADHD and oppositional-defiant symptoms at 24 months, although not as great as at 14 months. Combination and medication management did not differ significantly on direct comparisons, but in several instances—internalizing symptoms, parent-rated oppositional/aggressive symptoms, teacher-rated social skills, parent-child relations, and reading achievement—combination therapy proved superior to behavior modification and/or community care, whereas medication management did not.
THE WINNING COMBO
The MTA intensive medication strategy of medication management and behavior modification was superior to community care, despite the fact that two thirds of community care–treated participants received similar medication during the study, the team noted. Continuing medication use partly mediated the persisting superiority of combination and medication management.
“For ADHD symptoms, carefully crafted medication management (maintained through 14 months) was superior to behavior modification alone (faded by 14 months) and to routine community care that included medication,” the researchers concluded. Significant additional benefits of combination therapy over medication management and of behavior modification therapy over community comparison were not found.
Stimulants Control ADHD
But Stunt Growth |
Consistent
use of stimulants to treat children with attention-deficit/hyperactivity
disorder
(ADHD) will maintain its effectiveness—but will also suppress
patients’ growth. A study in the April Pediatrics reported that
at two years’ follow-up, children taking medication have a slower
growth rate than their nonmedicated peers, equivalent to 1 cm per year.
The study followed the 540 children who had participated in the Multimodal
Treatment Study of ADHD (MTA), an earlier randomized clinical trial comparing
four treatment strategies.
Intent-to-treat
analyses revealed group differences on ADHD symptoms ratings, with
better outcome
in groups of participants who were assigned
the medication algorithm—medication alone and medication combined
with behavioral modification—than in those who were not—behavior
modification alone and community comparison. However, the effect size
was reduced by 50% from the end of treatment to the first follow-up.
The convergence of outcomes suggested differential changes by treatment
group between 14 and 24 months, which the follow-up study explored, both
for benefits of treatment and for side effects on growth.
“We documented reported medication use at 14- and 24-month assessments
and formed four naturalistic subgroups,” the researchers explained.
The subgroups were formed to reflect the sequence of medication use over
time: medication/medication, medication/no medication, no medication/medication,
and no medication/no medication. “Then we performed exploratory
mediator analyses to evaluate effects of changes in medication use on
14- to 24-month change scores of effectiveness (symptom ratings) and
growth (height and weight measures).”
The groups
with the greatest improvement at the end of the treatment phase—those receiving combination medication and behavioral modification—deteriorated
during the follow-up phase, but the other two groups—those receiving
behavioral modification and those in community care—did not. There
were no significant differences in the 14- to 24-month growth rates among
the randomly assigned groups, in contrast to significant growth suppression
in the combination and medication management groups at the end of the
treatment phase.
Changes
in medication use mediated the 14- to 24-month change in ADHD symptom
ratings. The
subgroup that reported stopping medication showed
the largest deterioration, the subgroup that consistently reported medication
use or never reported medication use showed modest deterioration, and
the subgroup that reported starting medication showed improvement. Changes
in medication use also mediated growth effects—the subgroup that
consistently reported medication use showed reduced height gain compared
with the subgroup that never reported medication use, which actually
grew faster than predicted by population norms. |
Suggested Reading
MTA Cooperative
Group. National Institute of Mental Health Multimodal Treatment Study of
ADHD follow-up: changes in effectiveness and growth
after the end of treatment. Pediatrics. 2004;113:762-769. |
—Heidi W. Moore
Suggested Reading
MTA Cooperative Group. National Institute of Mental Health Multimodal Treatment Study of ADHD follow-up: 24-month outcomes of treatment strategies for attention-deficit/hyperactivity disorder. Pediatrics. 2004;113:754-761.
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