Several Treatments Show Efficacy in Kids With ADHD

Children who received medication management had fewer symptoms than other groups at 14 and 24 months after randomization. However, the take-home message from the follow-up, which received prominent coverage in the lay press, was that the disadvantage disappeared at 36 months. All of the groups showed symptom improvement over baseline.

The original MTA studies included 579 children randomized to receive medication management, behavior therapy, a combination of medication management and behavior therapy, or usual care in the community. The study treatments lasted 14 months.

At three years, 485 of the original 579 subjects participated in the follow-up, then aged 10 to 13. In contrast to the significant advantage of the treatment over behavior therapy and community care for ADHD symptoms at 14 and 24 months, treatment groups did not differ significantly on any measure at 36 months.

The percentage of children taking medication less than 50 percent of the time changed between 14 and 36 months across the initial treatment groups: it significantly increased in the behavior therapy group (15 percent to 45 percent), significantly decreased in the combined treatment group (91 percent to 71 percent), and remained constant in the community care group (60 percent to 62 percent). Regardless of their treatment-use changes, all of the groups showed symptom improvement over baseline.

The investigators concluded that the disappearance of the medication advantage may be due to age-related decline in ADHD symptoms, changes in medication management intensity, starting or stopping medications altogether, or other factors not yet evaluated.

“This is a very interesting and useful collection of articles,” said APA Trustee and child psychiatrist David Fassler, M.D. “The researchers provide the kind of longer-term follow-up in real-world settings that's often missing from standard clinical trials.

“The results are also consistent with general clinical experience,” he said. “Ongoing treatment with medication can be extremely helpful for some children and adolescents with ADHD. However, treatment should be evaluated on a regular basis, and when medication is no longer needed, it should be discontinued.

“It's also not surprising that children in all treatment groups showed improvement over time with respect to the core symptoms of ADHD,” Fassler said. “This would be consistent with the natural history of the disorder for many young people.”

But Fassler also noted that a significant limitation was that the original MTA study did not include an untreated control group.

“Although the findings are interesting, they should be interpreted with caution in view of significant methodological issues and shortcomings,” he said. “The initial design didn't include an untreated control group, which would be important to more fully assess the overall efficacy of treatment.”

The follow-up report in JAACAP titled “Delinquent Behavior and Emerging Substance Use in the MTA at 36 Months: Prevalence, Course, and Treatment Effects” compared the delinquency and substance use rates in 487 children from the MTA study and 272 children in a local normative comparison group.

The MTA children had significantly higher rates of delinquency (27.1 percent) than the normative control group (7.4 percent) at 36 months. They also had significantly higher rates of substance use (17.4 percent versus 7.8 percent), including drugs, tobacco, and alcohol. These findings appear to contradict previous studies indicating that treatment with stimulants is protective against substance abuse.

In an interview with Psychiatric News, lead author Brooke Molina, Ph.D., cautioned against overinterpreting the findings. She is an associate professor of psychiatry and psychology at the University of Pittsburgh School of Medicine.

For example, the children in the follow-up study were 10 to 13 years old, too young to have developed anything like a true addictive disorder. “We are talking about experimentation with alcohol, tobacco, and marijuana, not abuse, dependence, or addiction,” Molina said.

She also emphasized that the controlled treatments in the MTA study lasted only 14 months.

“There have been findings in the literature that stimulant treatment protects kids, and we didn't find that,” Molina said. “The relative advantage of stimulant medication didn't hold up two and three years after treatment with regard to substance abuse.”

But Molina cautioned that the children's functioning could have been worse had they not received any treatment at all. “Because the study did not include a large group of untreated children with ADHD, we really don't know what their delinquency and substance use levels would have been if they'd received no treatment,” she said.

One treatment modality, however, appeared to outperform the others with regard to substance use. The researchers found that at 24 months, the children who received behavior therapy had significantly less substance use than the other MTA children. (At 36 months, it was also less but fell short of statistical significance.)

“That's a nice finding because it means that there were probably some ingredients in our behavior therapy that were protective,” Molina told Psychiatric News. Those ingredients include parent training and academic support, she said.

In general, Molina said the findings indicate that clinicians need to follow children with ADHD over time, and especially as they enter adolescence, regardless of the status of their treatment for the core symptoms of ADHD.

“Clinicians should support parents to stay involved through adolescence,” she said. “Clinicians need to stick with the family and help them understand that ongoing parental involvement and monitoring are important.”

Fassler emphasized also that study treatments lasted only 14 months.

“I would agree with the authors' conclusion that relatively brief treatment does not necessarily prevent serious problems from emerging as a child grows up,” he said. “Clearly, this is an issue that warrants further research. As physicians, we ultimately need to try and identify the kids who may be at particular risk and develop appropriate and effective strategies designed to reduce the incidence of such serious, long-term consequences.”

TheJAACAPreports can be accessed at<www.jaacap.com> under the August issue. ▪