ADHD in the Post-MTA Era

Behavioral Health Update
BHSI Newsletter Vol. 1, No. 1

ADHD in the Post-MTA Era: Real Pearls from Warring Oysters
Dexter Whittemore, MD and Paul Hill, PhD

The MTA ( Multimodal Treatment Study of Children With Attention Deficit Hyperactivity Disorder) was a 14 month multi site randomized clinical trial designed to address questions about separate and combined effects of pharmacological and behavioral treatment for children with ADHD. Because of its rigorous design and its powerful statistical base (n=579), the MTA, first published in 1999, has become a sentinel study in the understanding of the disorder.

Preliminary results from the study showed that stimulant medication alone and treatment with combined medication/behavioral therapy were of equal efficacy and, furthermore, that both of these modalities were superior to behavioral therapy alone and to the typical treatment afforded by clinicians in their community. A major professional controversy has arisen because of the study's arguable implication that behavioral therapy is an unnecessary addition to medication management. Ongoing analysis of the data and numerous follow-up studies continue. These efforts have indicated that combined treatment had a statistically significant and clinically meaningful advantage over medication management and all other therapy conditions. For example, combined treatment resulted in 12% more successes than medication management alone. The combined treatment group ended the study on 20% lower doses of medication than did the medication management group. Also, combined treatment showed modest superiority in treating non-core ADHD symptoms. Despite the sometimes conflicting conclusions from this work, some very useful practice pearls are notable.

Medication Pearls:
Medication should be the first intervention but certainly not the only one. The addition of medication to psychosocial interventions more than doubles the number of cases that are successfully treated (from 30% to 62%). Girls and boys respond equally well. Once on medication, other interventions and accommodations are much more likely to be effective. When the basic deficits in behavioral and emotional inhibition and working memory have been corrected or improved with medication, behavioral techniques can be utilized to teach enduring coping strategies. Doses should be titrated to achieve maximum benefit, not merely adequate benefit. Pediatric patients' return visits should occur every month during the initial treatment phase to allow active reassessment and titration of dose as well as early identification of problems as they arise. (Thereafter, until the patient has demonstrated at least two years of stable functioning with maximum control of residual ADHD symptoms, we recommend that the patient be followed with rating scales and visits a minimum of every two to three months.)

Therapy Pearls:
* Important therapy components include education of the patient and family regarding: (a) avoidance of short and long-term effects of untreated ADHD, (b) personal (and parent) skills to manage ADHD and improve peer relationships, (c) external tools to supplement internal limitations, and (d) home and school interventions and accommodations.
* Parent training plus a simple home-school daily report card is arguably the most essential component of behavioral therapy for ADHD and the most cost effective.
* Combining a behavioral component with medication is the most effective treatment for comorbid conditions and non-core ADHD symptoms such as oppositional and aggressive symptoms, internalizing symptoms, family relationships, academic achievement, and social skills.
* In the MTA, parents significantly preferred conditions with a behavioral component and these conditions lead to the most significant improvement in parent-child relationships.

Longer-term follow-up studies thus far indicate that:

* Stimulant medication is clearly beneficial, but the effects do not last beyond medication termination. In contrast, the effects of behavioral interventions remain when medication is faded. Preliminary data from 24-month follow-up of the MTA seems to support this as outcomes for medication groups are declining while outcomes for psychosocial interventions are remaining constant.
* Comorbidity should influence choice of treatment components. Despite long-standing clinical beliefs to the contrary, clients with ADHD and anxiety will respond equally well to medication, psychosocial interventions, or some combination. Subjects with ADHD only and ADHD with comorbid oppositional defiance (ODD) or conduct disorder (CD) respond best to treatments including stimulant medications. Subjects with ADHD, anxiety, and ODD/CD respond best to a combined treatment approach.

We strongly recommend that all patients with ADHD concurrently receive:

* Stimulant medication trials.
* Referral to a therapist with expertise treating ADHD.