Daniel Carlat, MDDr. Carlat has disclosed that he has no significant relationships with or financial interests in any commercial companies pertaining to this educational activity.
Six short years ago, an influential study came out in Archives of General Psychiatry that was widely interpreted as showing that therapy adds little of value to the treatment of ADHD (Arch Gen Psychiatry 1999; 56:1073-1086). This was the “MTA Study,” (Multimodal Treatment study of children with ADHD) and it was seen as particularly legitimate because it was funded entirely by the NIMH. It was also the largest placebo-controlled study of stimulants ever published.
Children with ADHD (combined type) between the ages of 7 and 10 were recruited through six different sites, all of them academic centers. A total of 579 children were randomly assigned to one of four treatment groups: medication management, intensive behavioral treatment, combined medication and behavioral treatment, and standard community care (which generally included medication treatment).
Kids in the “medication-only” group received much more than a mere stimulant.
After 14 months of treatment, the kids were evaluated with standard assessment instruments. The results? Both the combined and medication groups fared better than the behavioral treatment and community care groups. There were no differences in ADHD symptoms between combined and medication. The question immediately arose: why provide expensive therapy to these kids at all, since combining intensive therapy with meds yielded no advantage over meds alone?
Well, the results were not so cut and dried.
While combined treatment did not do statistically better than meds alone, the kids in the combined group improved more in several non-ADHD symptom domains than kids in community care and therapy alone. These symptoms included oppositional/aggressive symptoms, internalizing symptoms, teacher-rated social skills, parent-child relations, and reading achievement; meds alone did not surpass the other groups in any of the non- ADHD symptom domains. In addition, kids in the combined group got by on lower doses of Ritalin (average 31.2 mg QD) than those in the medication group (37.7 mg). Thus, while therapy may do little for the core symptoms of ADHD, it helps mitigate problems that are equally troublesome in these kids, particularly oppositionality and poor relationships with parents and peers.
But there is yet another problem with the conclusion that this study endorses a “medication-only” approach to treating ADHD. One of the major, but underemphasized, results of the MTA study is that kids randomized to the medication group did significantly better than kids randomized to standard community care, most of whom also were prescribed medications. What accounted for this difference?
The difference was that the medication- only condition included a lot of extra care and monitoring than your typical ADHD kid receives in the doctor’s office. Here are the major elements of the MTA’s “medication-only” treatment protocol:
Clinicians prescribing medication were required, according to written algorithm, to continue titrating the dose of stimulants up to the point of optimal effectiveness.
Medication visits were monthly and lasted a full half-hour.
Clinicians provided “support, encouragement, and practical advice” without providing the behavioral therapy that was being tested in other arms of the study.
Parents were given readings about ADHD.
Each month, clinicians reviewed information on the child’s symptoms from both parents and teachers
I suspect that there aren’t many readers out there who schedule monthly half-hour medication visits for stimulant monitoring, who make sure to get teacher evaluations at every session, who give out special psychoeducational material to parents, and who use a research-driven algorithm to ensure the stimulant dose gets high enough, quickly enough. But one of the lessons of the MTA study is that we probably should be doing all these things if we want to get our patients well.
TCR VERDICT: Meds for core symptoms, therapy for all else