Treatment Strategies for ADHD
From MindLinc Wiki
Clinical Questions: How do long-term medication and behavioral treatments compare with one another? Are there additional benefits when they are used together? What is the effectiveness of systematic, carefully delivered treatments vs routine community care?
Background: ADHD has a prevalence of 3-5% in school-aged children, and accounts for 30-50% of child mental health referrals. ADHD causes impairment across most all domains of functioning. While the treatment of choice for ADHD at this point is stimulants, little is known about the long-term effectiveness of these meds, and there are wide variations in the way stimulants are used. There is also limited evidence about the effectiveness of behavioral treatments for ADHD, both alone and in combination with medication.
Methods:
Design/Setting: Randomized clinical trial using samples from 6 different sites. Referral sources for each site included mental health settings, pediatricians, advertisements, and school notices. 579 children were assigned randomly to medication mgmt, behavioral treatment, combined treatment, or community care for 14 months 1. Med mgmt: 28 day, double-blind, daily-switch titration of methylphenidate, using 5 randomly-prdered repeats each of placebo, 5mg, 10mg, and 15mg/20mg.. Most effective dose determined, blind broken. If poor response to methylphenidate, then alternates tried: dextroamphetamine, pemoline, imipramine, others. Pts seen Qmonth for med mgmt. 2. Behavioral Treatment: Parent training, total 27 group and 8 individual sessions. Child-focused treatment was an intense summer treatment program (8 wks, 5 days/week, 9 hrs/day). School-based treatment was 10-16 sessions of biweekly teacher consultation and 12 weeks of a part-time aide working directly with the child. 3. Combined Treatment: 1 & 2, with close collaboration between providers of each. 4. Community Care: pts got a report of their initial assessments and a list of community mental health providers.
Population : Male and female children aged 7-9.9; in grades 1-4; living with same primary caretaker >6 months; all met DSM-IV criteria for ADHD as evaluated using DISC, parent report, version 3.0, supplemented with up to 2 sx identified by teachers for cases falling just below the DISC diagnostic threshold.
Exclusion criteria: see Table 1
Assessment Methods/Outcomes: 6 domains; subjects assessed along these domains at baseline, 3mos, 9mos, and 14mos 1. ADHD symptoms: parent and teacher SNAP ratings on inattention/hyperactivity-impulsivity subscales 2. Oppositional/aggressive symptoms: parent and teacher SNAP ratings on oppositional-defiant disorder subscale 3. Social Skills: parent and teacher completed subscale from the Social Skills Rating System (SSRS) 4. Internalizing Sx (Anxiety, Depression): internalizing subscale of SSRS and children’s self-ratings on MASC 5. Parent-child relations: 2 composite scales from a parent-child relationship questionnaire 6. Academic achievement: 3 subscales from the WISC (reading, math, spelling) Assessment of domains 1-5 were augmented by blinded ratings of school-based ADHD and ODD/aggression symptoms using the Abikoff Classroom Observational System, and social skills and peer relations using peer sociometric procedures.
Analysis: Intention-to-treat, random-effects regression analyses, with Bonferonni corrections for multiple comparisons.
Validity: F/U complete? Yes. Randomized? Yes; Intention to treat? Yes. Similar at baseline? Yes. Blinded? Yes. Equal treatment? Yes.
Results: (See Table 5) 1. How do long-term medication and behavioral treatments compare with one another? Med mgmt > behav for ADHD sx, as shown by parents’ and teachers’ ratings of inattention and teachers’ ratings of hyperactivity/impulsivity. No significant difference between med mgmt and behave on any other outcomes. 2. Are there additional benefits when they are used together? Comb ≈ Med Mgmt across all domains, but comb methylphenidate doses < med mgmt doses. Comb, Behav > Med mgmt with regard to parent satisfaction. Comb > behav in ADHD sx as shown by parent/teacher ratings of inattention and parent-rated hyperactivity/impulsivity. The following results did not reach significance after Bonferroni correction: Comb > behav for ADHD sx, as shown by parent/teacher rating of inattention and parent rating of hyperactivity/impulsivity. Comb > behav on parent- rated OD/aggressive behavior, parent-rated internalizing sx, and WISC reading score. 3. What is the effectiveness of systematic, carefully delivered treatments vs routine community care? Comb, Med mgmt > CC, and behav≈ CC for parent and teacher-reported ADHD sx. Comb > CC on all 5 non-ADHD domains.
Comments: Strengths:: well-organized; rigorous; generalizable; long-term F/U; looked at non-ADHD domains Weaknesses:: behavioral intervention not necessarily realistic; limited power to detect small effect sizes
** CLINICAL BOTTOM LINE** : This study supports medication management as the first-line treatment for ADHD symptoms. Adding behavioral interventions may be beneficial in treating non-ADHD symptoms that are found more commonly in children with ADHD, and they may allow for lower minimum effective dosing of medications. Although the benefit of these behavioral interventions was modest in this study, further study is needed to clarify the role of behavioral interventions in treatment of ADHD throughout development.
Presented by Alexandra Spessot, MD on 10/30/06
