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QUESTION: In children with attention deficit hyperactivity disorder (ADHD), what is the long term effectiveness of pharmacotherapy and behaviour therapy, alone and in combination?
Clinical centres in the US.
579 children between 7 and 10 years of age, in grades 1 through 4, with a diagnosis of DSM-IV ADHD Combined Type. All children were in residence with the same primary caretaker for ≥6 months. Exclusion criteria included situations that would prevent families' full participation in assessments or treatment, or that might require additional treatments incompatible with study treatments.
144 children were allocated to medication management (titration followed by monthly visits), 144 to behavioural treatment (parent, school, and child component, with therapist involvement gradually reduced over time), 145 to a combination of medication management and behavioural treatment, and 146 to standard community care (treatment by community providers).
Main outcome measures
Change in ADHD symptoms and academic achievement.
Analysis was by intention to treat. Only those outcomes with >80% follow up are reported here. All 4 treatment groups showed reductions in symptoms over time. Medication management was found to be superior to behavioural treatment when reviewing parents' and teachers' rating of inattention (p=0.001) and parents' rating of hyperactivity-impulsivity (p=0.001). Children in the combined treatment group showed greater improvement than those given behavioural treatment alone when reviewing parents' and teachers' rating of inattention (p=0.001 and p=0.005, respectively), parents' rating of hyperactivity-impulsivity (p=0.001), and parents' rating of aggression (p=0.001). Combined treatment and medication management were superior to community care for parent and teacher reported ADHD symptoms (p=0.001), whereas behavioural treatment was not. No difference existed between medication management and combined treatment in direct comparisons.
For attention deficit hyperactivity disorder (ADHD) symptoms, medication management was superior to behavioural treatment and to standard community care. Combined treatment was not more effective than medication management for core ADHD symptoms.
This landmark study by the MTA Cooperative Group sets a high standard for the future evaluation of interventions designed to treat child and adolescent psychiatric disorders. Strengths of the study include its large sample of participants, the use of random assignment of participants to 1 of 4 treatment strategies, the high retention of participants during the 14 months of the study and the careful attention paid to the content of the treatment strategies. A number of commentaries have already been published in response to the initial findings from the study.1–3 The decision to assess outcomes at a point when the intensive behavioural interventions had faded while medication management continued has been a source of considerable discussion. The decision to assess outcomes at that point was based on the assumption that parents and teachers would maintain behavioural techniques after support was reduced but symptom reduction would not be maintained after medication withdrawal.
All the treatment strategies studied achieved a substantial reduction in ADHD symptoms. The medication management strategy used, however, was more effective than the intensive behavioural strategy in reducing core ADHD symptoms and aggressive behaviour. In some other areas (eg, parent reported oppositional/aggressive symptoms, parent reported internalising problems, reading achievement), there was limited evidence that combined medication and intensive behavioural strategy was more effective than the medication or behavioural strategies alone. An important finding in this study was that the medication management achieved a greater reduction of core symptoms than routine community care, even though most of the children in the routine community care group received medication. This suggests that careful titration of medication based on close collaboration between parents, teachers, and clinicians is important to achieve the full benefits of medication management.
Improvements in the outcome of children with ADHD may be achieved by using more carefully crafted medication and behavioural strategies that are well coordinated with parents, teachers, and other professionals.
Source of funding: National Institute of Mental Health.
For correspondence: Dr P S Jensen, Department of Child Psychiatry, Unit 78, Center for the Advancement of Children's Mental Health, New York State Psychiatric Institute/Columbia University, 1051 Riverside Drive, New York, NY 10032, USA. Fax +1 212 543 5260.
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