Think beyond drug therapy for treating ADHD: Study says medicate and modify
■ Results from a large trial comparing four different treatment modalities offer complicated answers.
Treating children who struggle with attention-deficit/hyperactivity disorder poses a series of perplexing decisions for physicians and families.
Choose medication and risk being criticized for taking the easy way out with a difficult child. Choose behavioral modification and run the risk of using expensive health resources that may not be as effective. Choose neither and the child could miss out on valuable educational opportunities.
That's why much attention has been focused on the Multimodal Treatment Study of ADHD, a large randomized trial funded by the National Institute of Mental Health that sought to identify the optimal strategy for treating this disorder.
When the Archives of General Psychiatry published the first round of findings in December 1999, the take-home message seemed clear. Closely monitored medication was superior to even the most expensive behavioral interventions and was certainly superior to the lower doses of medication combined with less intensive follow-up that most kids were getting.
But the April Pediatrics offers two additional papers that made the best choice murky.
"The appropriate use of medication is going to be one of the factors overall that really helps to optimize outcomes, but it's not going to be enough, and we don't know what the other factors are going to be," said Glen R. Elliott, MD, PhD, one of the study leaders and director of child and adolescent psychiatry at the University of California, San Francisco.
Maintaining options, improvements
Specifically, during the 14-month trial, those children who received closely monitored medication management, including monthly physician visits and stimulant drugs either with or without behavioral treatment, seemed to fare the best. But in the 10 months after the study ended and the participants returned to usual care -- the focus of the recent papers -- these initial improvements were reduced by half.
Additionally, children in the medication-management arms of the study performed better overall than those who received behavioral treatment that included parent training, child-focused therapy and school-based interventions but no medication. Still, those in the latter category maintained most of their initial progress.
Similar results were noted with those who received standard care -- lower doses of medication and little more than an annual office visit -- from their own physicians.
"The findings that we had at 14 months continue to be visible but less robust because we're no longer controlling the treatment," said Dr. Elliott. "Did we teach patients and their families something that made one group uniquely better at getting the kind of care that the child needs compared to another treatment group? The answer is no."
Authors and other experts do point out that children whose progress declined the most had stopped taking medication. Thus, the study reinforced the concept that medication is the most effective treatment method.
Some said, however, that the drugs become less effective over time and that this study may point toward behavioral treatments as good options, particularly for parents who are uncomfortable with medicating their youngsters. The data indicate that parents and teachers tended to be more satisfied with behavioral modifications even though the children seemed to benefit less.
"Behavioral interventions were of some value," said Leonard Sax, MD, PhD, a family physician and psychologist based in Poolesville, Md. "And there's no question that if you maintain the same dose, you do see what appears to be a tolerance effect."
Critics also offered a reality check -- that access to all but standard care is difficult. The interventions used in this study, particularly the behavioral ones, were often cost-prohibitive, and there are few specialists to carry them out.
"The capacity to deal with these kids doesn't exist," said Michael Wasserman, MD, a pediatrician at the Ochsner Clinic in New Orleans. "You can't get them into these outstanding combined therapy programs. The insurance doesn't allow you to access them."
The authors also suggest that time- and money-intensive interventions may not be the best option. Instead, findings seemed to indicate the effectiveness of medication and to highlight an added benefit when it was combined with additional physician monitoring and contact.
"There's a tendency of community physicians to be less vigorous with their dosing," said Dr. Elliott. "It's important to get good sources of feedback about how the child is doing, and you need to see these kids more often than once a year."
But insurance and time constraints can get in the way.
"Parents don't want to pay the co-pays," said Dr. Wasserman. "Parents don't want to be inconvenienced, and kids have after-school activities."
There is also the question of the growth suppression of approximately half an inch per year on average found in this study.
Some doctors consider it a fair trade-off. "If a child is going to be one inch shorter, but he's going to have a good brain and good schooling, in my mind, it's probably worth it," Michael S. Kramer, MD, a Dallas family physician. "You're dealing with the potential of a child. With an education, there's a livelihood. Without an education, there's lots of risks."
But for others, this phenomenon is one more reason for caution. "There are risks associated with treatment," said Dr. Sax. "Before prescribing medication, doctors need to pause."