Study Explores Treatment Options for AD/HD

A new study on attention-deficit/hyperactivity disorder {AD/HD), released by the National Institute of Mental Health INIMHI, may quiet the "ongoing debate" over treatment for the disorder and allow real progress to begin.

The NIMH's Multimodal Treatment Study of Children with Attention-Deficit/ Hyperactivity Disorder (MTA), released in the December issue of the American Medical Association's Archives of General Psychiatry, is the longest and most thorough study ever completed comparing treatments for AD/HD.

Attention-deficit/hyperactivity disorder (AD/HD) is the most commonly diagnosed disorder of children, estimated to affect three to five percent of school age children. On average, at least one child in every classroom in the United States needs help for the disorder. The core symptoms include an inability to sustain attention and concentration, developmentally inappropriate levels of activity, distractibility and impulsivity.

"AD/HD is a major public health problem of great interest to many parents, teachers, health care providers and researchers. Up-to-date information concerning the safety and efficacy of treatments over a significant period of time is critical," said Steven E. Hyman, M.D., director of NIMH. In this landmark study, the first major clinical trial to look at childhood mental illness and the largest NIMH clinical trial to date, the NIMH and the Department of Education tested the leading treatments for AD/HD for long-term efficacy at multiple research sites in the U.S. and Canada.

Including nearly 600 elementary school children, ages 7-9, the MTA study randomly assigned them to one of four treatment programs: (1) medication alone; (2) behavioral treatment alone; (3) a combination of both; or (4) routine community care. "All children tended to improve over the course of the study, but they differed in the relative amount of improvement," said Peter Jensen, M.D., one of the primary NIMH collaborators for the study and senior advisor to the director of the NIMH, on assignment to Columbia University. "Nonetheless, determining what treatment will be most effective for a particular child is an important question that needs to be answered by each family in consultation with their health care professional."

The MTA study has demonstrated, on average, that carefully monitored medication management with monthly follow-up is more effective than intensive behavioral treatment for AD/HD. The combination of medication management and intensive behavioral treatments was also significantly superior to psychosocial treatments alone in reducing AD/HD symptoms. 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, and families and teachers reported somewhat higher levels of consumer satisfaction for those treatments that included the behavioral therapy components. Furthermore, the combination program allowed children to be treated over the course of the study with somewhat lower doses of medication.

"These results allow the AD/HD community to move on from the ongoing debate about best types of treatment, and make real progress by ensuring that every individual with AD/HD is actually receiving the best type of treatment," stated John Heavener, CEO of CHADD.

"We've been entrenched for a long time in a debate about what constitutes appropriate treatment," said Heavener. "Now we can begin addressing new questions - how do we make sure that providers and families dealing with AD/HD are aware of these findings, and how do we make sure the findings are being incorporated into treatment?"

The study also found 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, the MTA prescribing therapist met with the family for monthly, one-half hour visits with the parent and the child, to assess any concerns that the family might have regarding the medication or the child's AD/HD-related difficulties. 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. If the child was experiencing any difficulties, the MTA physician was encouraged to consider adjustments in the child's medication.

In comparison, the community treatment physician generally saw the children face-to-face only one or two times per year and for shorter periods of time each visit. Furthermore, they did not have any interaction with the teachers, and generally prescribed lower doses of stimulant medication.

Beth Kaplanek, president-elect of CHADD, feels that the differences between community procedures and those of the MTA study are of great concern. "The problem is that the less effective type of medication management - that available through the community - is the norm for most children with AD/EID," said Kaplanek. "It's imperative that we use the findings of this study to transform the quality and intensity of medication management among community providers."

"My hope is that this study will lead practitioners to transform current treatment practices," said Kaplanek, "not only by relying on the most successful types of treatments, but also in recognizing the necessity of frequent, involved contact in obtaining optimal success."

"This is a crucial moment in the history of AD/HD," said Heavener. "If we want the best possible future for children with AD/HD, we need the best possible treatment - that means helping providers in any way we can to get the word out and have improved standards of care available nationwide."

It is also important to note that these findings were replicated in six sites across the U.S. and Canada, despite substantial differences among sites in their samples socio-demographic characteristics. Therefore, the study's overall results are probably applicable and generalizable for the many children and families in need of treatment services for AD/HD. Research sites included Columbia University, New York, N.Y.; Duke University Medical Center, Durham, N.C.; Western Psychiatric Institute, Pittsburgh, PA; Long Island Jewish Medical Center, New Hyde Park, N.Y; University of California at Berkeley; University of California at Irvine and Montreal Children's Hospital, Canada.