diminished benefits of drugs in ADHD

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BabyPsychDoc

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http://www.msnbc.msn.com/id/29906327/

Without the benefit of having read the original paper (could not find a reference to it in the news story), I have tried to make some sense of this. So, in the long run kids that have not been given stimulants do as well (or as poorly - depending on the base-line level of disability and the socio-economic background, it seems) as those prescribed stimulants. Why is that? Could it be due to low level of patient compliance? Or, could it be explained by natural history of ADHD - symptoms improve as kids grow older? Or, is it because families of the non-drugged kids do not rely on the magic pill and invest extra time and effort into behavioural interventions/coping strategies?

Does anyone have a link to the full-text original article?

Thank you!

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"A yet-to-be-published study, Pelham added [read psychologist], found that 95 percent of parents who were told by clinicians to first try behavioral interventions for ADHD did so. When parents were given a prescription for a drug and then told to enroll their children in behavioral intervention programs, 75 percent did not seek out the behavioral approaches."


That first part about 95% of parents using behavior interventions seems kind of high from my limited experience.
 
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I haven't gotten a chance to review the whole article yet, but here is the abstract from pubmed:

Abstract said:
MTA at 8 Years: Prospective Follow-up of Children Treated for Combined-Type ADHD in a Multisite Study.

Molina BS, Hinshaw SP, Swanson JM, Arnold LE, Vitiello B, Jensen PS, Epstein JN, Hoza B, Hechtman L, Abikoff HB, Elliott GR, Greenhill LL, Newcorn JH, Wells KC, Wigal T, Gibbons RD, Hur K, Houck PR; the MTA Cooperative Group. The NIMH Collaborative Multisite Multimodal Treatment Study of Children With Attention-Deficit/Hyperactivity Disorder (MTA) was a National Institute of Mental Health (NIMH) cooperative agreement randomized clinical trial involving six clinical sites. Collaborators from the National Institute of Mental Health: Peter Jensen, M.D. (currently at Columbia University), L. Eugene Arnold, M.D., M.Ed. (currently at Ohio State University), Benedetto Vitiello, M.D. (Child and Adolescent Treatment and Preventive Interventions Research Branch), Kimberly Hoagwood, Ph.D. (currently at Columbia); previous contributors from NIMH to the early phase: John Richters, Ph.D. (currently at National Institute of Nursing Research); Donald Vereen, M.D. (currently at National Institute on Drug Abuse). Principal investigators and coinvestigators from the clinical sites are as follows: University of California, Berkeley/San Francisco: Stephen Hinshaw, Ph.D. (Berkeley), Glen Elliott, Ph.D., M.D. (San Francisco); Duke University: C. Keith Conners, Ph.D., Karen Wells, Ph.D., John March, M.D., M.P.H., Jeffery Epstein, Ph.D.; University of California, Irvine/Los Angeles: James Swanson, Ph.D. (Irvine), Dennis Cantwell, M.D., (deceased, Los Angeles), Timothy Wigal, Ph.D. (Irvine); Long Island Jewish Medical Center/Montreal Children's Hospital: Howard Abikoff, Ph.D. (currently at New York University School of Medicine), Lily Hechtman, M.D. (McGill University); New York State Psychiatric Institute/Columbia University/Mount Sinai Medical Center: Laurence Greenhill, M.D. (Columbia), Jeffrey Newcorn, M.D. (Mount Sinai School of Medicine); University of Pittsburgh: William Pelham, Ph.D. (currently at State University of New York at Buffalo), Betsy Hoza, Ph.D. (currently at University of Vermont), Brooke Molina, Ph.D., Patricia Houck, MS. Original statistical and trial design consultant: Helena Kraemer, Ph.D. (Stanford University). Follow-up phase statistical collaborators: Robert Gibbons, Ph.D. (University of Illinois at Chicago), Sue Marcus, Ph.D. (Mt. Sinai College of Medicine), Kwan Hur, Ph.D. (University of Illinois at Chicago). Collaborator from the Office of Special Education Programs/U.S. Department of Education: Thomas Hanley, Ed.D. Collaborator from Office of Juvenile Justice and Delinquency Prevention/Department of Justice: Karen Stern, Ph.D.

OBJECTIVES:: To determine any long-term effects, 6 and 8 years after childhood enrollment, of the randomly assigned 14-month treatments in the NIMH Collaborative Multisite Multimodal Treatment Study of Children With Attention-Deficit/Hyperactivity Disorder (MTA; N = 436); to test whether attention-deficit/hyperactivity disorder (ADHD) symptom trajectory through 3 years predicts outcome in subsequent years; and to examine functioning level of the MTA adolescents relative to their non-ADHD peers (local normative comparison group; N = 261). METHOD:: Mixed-effects regression models with planned contrasts at 6 and 8 years tested a wide range of symptom and impairment variables assessed by parent, teacher, and youth report. RESULTS:: In nearly every analysis, the originally randomized treatment groups did not differ significantly on repeated measures or newly analyzed variables (e.g., grades earned in school, arrests, psychiatric hospitalizations, other clinically relevant outcomes). Medication use decreased by 62% after the 14-month controlled trial, but adjusting for this did not change the results. ADHD symptom trajectory in the first 3 years predicted 55% of the outcomes. The MTA participants fared worse than the local normative comparison group on 91% of the variables tested. CONCLUSIONS:: Type or intensity of 14 months of treatment for ADHD in childhood (at age 7.0-9.9 years) does not predict functioning 6 to 8 years later. Rather, early ADHD symptom trajectory regardless of treatment type is prognostic. This finding implies that children with behavioral and sociodemographic advantage, with the best response to any treatment, will have the best long-term prognosis. As a group, however, despite initial symptom improvement during treatment that is largely maintained after treatment, children with combined-type ADHD exhibit significant impairment in adolescence. Innovative treatment approaches targeting specific areas of adolescent impairment are needed.Clinical trial registration information-Multimodal Treatment Study of Children With Attention Deficit and Hyperactivity Disorder. URL: http://www.ClinicalTrials.gov. Unique identifier: NCT00000388.

Sounds interesting. It seems that 6-7 years is a huge lag time to follow-up on patients recieving treatment. I think what may be important, and I will try to look into when I review the article, is what were these kids doing after their 14 month treatment period (the abstract only says this was "largely maintained)? The original 1999 study had an N= 579. Which means 140, or almost 25% of their original cases were lost to follow-up. This might have biased the data especially if most of these 140 were over-represented from a particular treatment group. Again though, I'll read into that... these are just some thoughts/questions I hope get addressed when I read through the article.

Nardo
DB Pediatrician
 
I haven't gotten a chance to review the whole article yet, but here is the abstract from pubmed:



Sounds interesting. It seems that 6-7 years is a huge lag time to follow-up on patients recieving treatment. I think what may be important, and I will try to look into when I review the article, is what were these kids doing after their 14 month treatment period (the abstract only says this was "largely maintained)? The original 1999 study had an N= 579. Which means 140, or almost 25% of their original cases were lost to follow-up. This might have biased the data especially if most of these 140 were over-represented from a particular treatment group. Again though, I'll read into that... these are just some thoughts/questions I hope get addressed when I read through the article.

Nardo
DB Pediatrician

Thank you, Nardo - really appreciate this! I agree with both your points - re loss to follow-up and re "largely maintained treatment effect". I'll check out the full text now.
 
"A yet-to-be-published study, Pelham added [read psychologist], found that 95 percent of parents who were told by clinicians to first try behavioral interventions for ADHD did so. When parents were given a prescription for a drug and then told to enroll their children in behavioral intervention programs, 75 percent did not seek out the behavioral approaches."


That first part about 95% of parents using behavior interventions seems kind of high from my limited experience.

Well, no, parents are not really keen on behavioural interventions compared to pills. However, if they are not presented with choice and basically told that they won't get the drugs until after they have tried behavioural techniques (as it is the case in the UK), most would probably do so (even if just to get the doc off their back and get that coveted script for Ritalin). Now, I can see that insurance companies would be probably less keen to cover behavioural therapy compared to stimulants - could that also be a factor in relatively infrequent use of behavioural techniques?
 
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