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1 Psychological vs Pharmalogical Treatment

In Europe, where the prescription of stimulants has been restricted by custom and by law, clinical guidelines recommend an initial rigorous trial of multiple psychosocial interventions such as behaviour modification, cognitive therapy, family therapy and teacher consultation. In North America, where the prescription of stimulants has been accepted for decades and some restrictions have been relaxed, clinical guidelines recommend an initial rigorous pharmacological trial [9]. Over the past decade, the prescriptions for these stimulants (methylphenidate (MPH) and amphetamine (AMPH)) have increased from less that 2 million in 1991 to over 10 million in 2001, and now it is estimated that approximately 6 % of school-age children are identified and treated with these drugs (about 3 million/year in the US) [10].

2 Treatment Study of Children with ADHD

In the The Multimodal Treatment Study of Children with ADHD Cooperative Group (MTA) [5], the largest and longest study of children with attention-deficit/hyperactivity disorder (ADHD) combined type, aged 7 years to 9.9 years, were randomly assigned to 14 months of treatment in four groups: rigorous medication management; intensive behavioral treatment; the two combined; or standard community care (2∕3 treated with medication). All groups in the study showed reduction of symptoms over time [5]. However, the children in the combined treatment and the medication management groups showed further reduction in core ADHD symptoms than those in behavioral alone, or community care groups [5].

This validates the clinical experience that children who largely adhere to a well-titrated regimen of stimulants continue to benefit significantly for at least 14 months [2]. After the MTA study completed, the caregivers/children determined their continued treatment. Interestingly, most children who were treated with stimulants did not continue this treatment. After 8 years, only 32.5 % of ADHD cases were being treated with stimulant medications [8].

2.1 Follow-ups

By the 3 year follow-up assessment point, the initial relative benefits of assignment to the medication conditions and of current medication use were no longer significant [1, 3, 6]. In an 8 year follow-up [4], treatment-related improvements during the study were generally maintained, but differential treatment efficacy was lost. There were no differences between the four initially assigned treatment groups on repeated measures of psychiatric symptoms, academic function, and social functioning [4]. There was also no difference between groups for long-term outcomes, e.g. substance use or delinquency [3, 4].

This suggests that the relative benefits of childhood treatment with stimulant medication, compared with non-pharmacological treatments—improvement in cognitive deficits as well as reductions in symptom severity—may dissipate after a 2 year to 3 year period, whether or not the medication component of treatment is continued or withdrawn [4, 6, 7].

3 Following Academic Acheivement

In a different long-term study, where subjects had self-selected medication status for 9 years, groups separated into medicated > 1 year (average 5.3 years) or no treatment/short-term treatment, differed on 3 measures of academic achievement and on grade point average, with the medicated group outperforming the non-medicated group regardless of current medication status [8]. Compared with non-ADHD controls, the subgroup of ADHD adolescents not taking medication at follow-up had a more pervasive pattern of significant deficits than the subgroup of ADHD adolescents taking medication. The ADHD subgroup on medication had better performance on sustained attention and verbal learning tests [8].

Acronyms

ADHD

attention-deficit/hyperactivity disorder

AMPH

amphetamine

MPH

methylphenidate

MTA

The Multimodal Treatment Study of Children with ADHD Cooperative Group

References