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| The NIMH Multimodal Treatment Study New look at ADHD data suggests lasting effect of behavioral treatment |
| The NIMH Multimodal Treatment Study of Children with attention-deficit/hyperactivity disorder (the MTA) is a randomized clinical trial that compared the relative effectiveness of different treatments in a sample of 579 children with ADHD, ages 7 to 9 years. The study was conducted under an NIMH-sponsored cooperative agreement, beginning in 1995. The children were randomly assigned to one of four treatment modes: (1) medication alone; (2) psychosocial/behavioral treatment alone; (3) a combination of both; or (4) routine community care. Six clinical sites and 18 nationally recognized authorities in ADHD participated in the study. Twenty percent of the participants were girls and 39% were ethnic minorities. The behavioral treatment component of the MTA was far more intense than could ever be obtained in a community setting. It involved 35 parent training sessions, 10 to 16 face-to-face teacher consultations, an eight-week, all day summer treatment program, and 12 weeks of a half-time paraprofessional, behaviorally-trained aide in the classroom of each child, all tied together by a daily report. This was gradually tapered, or "faded" over the 14 month period. In most cases, contact had been reduced to once monthly or stopped altogether by the 14-month end point. Researchers recently prospectively assessed the data gathered at the 9-month time point in order to compare it to the end-point data. The goal was to see the relative effect of medication management and behavioral treatment at the 9-month point, while the behavioral treatment component was still intense. The 14-month results showed that for ADHD and oppositional defiant disorder (ODD) symptoms the medication treatment, whether alone or in combination with behavioral treatment, was significantly superior to behavioral treatment alone and to routine community care. Furthermore, the combination of medication treatment and behavioral treatment was not significantly better than medication alone.Using intention-to-treat (ITT) analysis - where data from all participants enrolled in the trial is evaluated, rather than data only from those who complete the trial - the researchers found that the nine-month data were essentially the same as the 14-month data. "Contrary to misinterpretations of the data widely disseminated (to our dismay) earlier, these conclusions are not tantamount to concluding that [behavioral treatment] is ineffective for ADHD," the researchers note. "On the contrary, the group with intensive behavioral treatment did at least as well in the ITT analysis as did the community care, two-thirds of whom were medicated in the routine community manner." Arnold LE, Chuang S, Davies M, et al.: Nine months of multicomponent behavioral treatment for ADHD and effectiveness of MTA fading procedures. Journal of Abnormal Child Psychology, 2004; 32(1):39-51. Correspondence to: Dr. L. Eugene Arnold; e-mail: Arnold.6@osu.edu. Long-term effects of methylphenidate studied Drugs often prescribed for children to treat attention deficit hyperactivity disorder (ADHD) may have long-term affects on the developing brain. Three animal studies published in Biological Psychiatry suggest that in rats, early exposure to methylphenidate (Ritalin) leads to behavioral disturbances later in life. The three studies exposed young rats (at various developmental stages equivalent to childhood and adolescence) to low-doses of methylphenidate and then assessed various behaviors in the adult rats. The "pre-adolescent" rats exposed to methylphenidate exhibited increases in depressive-like signs as adults. One study demonstrated that compared to untreated rats, those exposed to methylphenidate during development were more sensitive to stress and increased anxiety-like behavior as adults. In an accompanying editorial, Dr. Nora Volkow, director of the National Institute on Drug Abuse (NIDA) and Dr. Thomas Insel, director of the National Institute of Mental Health (NIMH), addressed the importance of these studies as well as the limitations in generalizing these results to treatment of children with ADHD. These studies were performed on "healthy" rats and used a different route of administration (intraperitoneal rather than oral). "These studies remind us how limited our knowledge is of the neurochemical and functional characteristics of the human brain during childhood and adolescence and on the effects of psychotropic drugs on brain development," Drs. Volkow and Insel wrote. Regardless of the results the current findings underscore the importance of ensuring a proper diagnosis of ADHD before initiating clinical treatment with a stimulant medication." Source: Biological Psychiatry, Volume 54, Issue 12, 15 Dec 2003. A complete discussion of the studies will be in the February 2004 The Brown University Child and Adolescent Psychopharmacology Update. If you are interested in receiving a reprint of this article, please contact customer service at 800-333-7771 or via e-mail: manissescs@manisses.com. |