Improvement Following ADHD Treatment Sustained in Most Children
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Linked Problems Persist Into Adolescence - Major Follow-up Study
Most children treated in a variety of ways for attention deficit
hyperactivity disorder <http://www.nimh.nih.gov/healthinformation/
adhdmenu.cfm>
(ADHD) showed sustained improvement after three years in a major
follow-up study
funded by the National Institutes of Health's (NIH) National Institute
of Mental Health (NIMH). Yet increased risk for behavioral problems,
including delinquency and substance use, remained higher than normal.
The study followed-up children who had participated in the Multimodal
Treatment Study of Children with Attention Deficit Hyperactivity
Disorder (MTA).
Initial advantages of medication management alone or in combination
with
behavioral treatment over purely behavioral or routine community care
waned in the years after 14 months of controlled treatment ended.
However, Peter Jensen, M.D., Columbia University, and colleagues
emphasized that "it would be incorrect to conclude from these results
that treatment makes no difference or is not worth pursuing."
Their report is among four on the outcome of the MTA study published
in
the August, 2007 Journal of the American Academy of Child and
Adolescent
Psychiatry (JAACAP).
"We were struck by the remarkable improvement in symptoms and
functioning across all treatment groups," explained Jensen.
After three years, 45-71 percent of the youth in the original
treatment
groups were taking medication. However, continuing medication
treatment
was no longer associated with better outcomes by the third year.
"Our results suggest that medication can make a long-term difference
for
some children if it's continued with optimal intensity, and not
started
or added too late in a child's clinical course," added Jensen.
For the followup study, a multi-site research team evaluated, at ages
10-13, 485 children from the original MTA study
<http://www.nimh.nih.gov/childhp/mtaqa.cfm> , the first major
randomized
trial comparing different treatments for ADHD, published in l999. That
study found that intensive medication management alone or in
combination
with behavioral therapy produced better outcomes than just behavioral
therapy or usual community care.
Ratings from families and teachers favored the combination treatment,
which allowed for somewhat lower medication doses. Also, the careful
management of medication by MTA physicians produced better outcomes
than
medication provided through usual community care sources.
After the 14 months of assigned treatments ended, families were free
to
choose from treatments available in their communities.
To understand why the initial advantage of medication wore off, the
researchers examined medication use patterns that emerged after formal
treatment in the study ended. They found that children who had been
assigned to intensive behavioral treatment were more likely to begin
taking medication, while those who had been taking medication were
more
likely to stop. For example, among children originally in the
behavioral
treatment group, the incidence of high medication use increased from
14
to 45 percent.
In a secondary analysis of the data that searched for possible
explanations for the findings, in the same issue of the JAACAP,
researchers led by James Swanson, Ph.D., University of California at
Irvine, reported finding substantial individual variability in
responses
to medication. They identified three groups of children with different
patterns of response. One group, about a third of the children, showed
a
gradual, moderate improvement; a second group, about half of the
children, showed larger initial improvement, which was sustained
through
the third year; a third group, about 14 percent of the children,
responded well initially, but then deteriorated as symptoms returned
during the second and third years. Swanson and colleagues suggested
"trial withdrawals" for some children to determine if they still need
to
take medications.
Another report by Swanson and colleagues in the same issue of the
JAACAP
confirmed an earlier finding from the MTA study that taking medication
slowed growth. A group of 65 children with ADHD who had never taken
medication grew somewhat larger â€" about three-fourths of an inch
and 6 pounds more, on average â€" than a group of 88 peers who
stayed on medication over the three years. Growth rates normalized for
the children on medication by the third year, but they had not made up
for the earlier slowing in growth.
In a fourth article, Brooke Molina, Ph.D., University of Pittsburgh,
and
colleagues reported that, despite treatment, the children with ADHD
showed significantly higher-than-normal rates of delinquency (27.1
percent vs. 7.4 percent) and substance use (17.4 percent vs. 7.8
percent) after three years. Earlier evidence of lower substance use
rates among children who had received intensive behavioral therapy had
lessened by the third year. "These findings underscore the point that
ADHD treatment for one year does not prevent serious problems from
emerging later," noted Molina.
The follow-up of the MTA sample will continue as the participating
children go through adolescence and enter adulthood.
The following researchers participated in the studies:
Three-year Follow-up of the NIMH MTA Study. Peter S. Jensen, L. Eugene
Arnold, James M. Swanson, Benedetto Vitiello, Howard B. Abikoff,
Laurence L. Greenhill, Lily Hechtman, Stephen P. Hinshaw, William E.
Pelham, Karen C. Wells, C. Keith Conners, Glen R. Elliott, Jeffery N.
Epstein, Betsy Hoza, John S. March, Brooke S.G. Molina, Jeffrey H.
Newcorn, Joanne B. Severe, Timothy Wigal, Robert D. Gibbons, Kwan Hur
Secondary Evaluations of MTA 36-Month Outcomes: Propensity Score and
Growth Mixture Model Analyses. James M. Swanson, Stephen P. Hinshaw,
L.
Eugene Arnold, Robert D. Gibbons, Sue Marcus, Kwan Hur, Peter S.
Jensen,
Benedetto Vitiello, Howard B. Abikoff, Laurence L. Greenhill, Lily
Hechtman, William E. Pelham, Karen C. Wells, C. Keith Conners, John S.
March, Glen R. Elliott, Jeffery N. Epstein, Kimberly Hoagwood, Betsy
Hoza, Brooke S.G. Molina, Jeffrey H. Newcorn, Joanne B. Severe,
Timothy
Wigal, and the MTA Cooperative Group
Effects of Stimulant Medication on Growth Rates Across 3 Years in the
MTA Follow-up. James M. Swanson, Glen R. Elliott, Laurence L.
Greenhill,
Timothy Wigal, L. Eugene Arnold, Benedetto Vitiello, Lily Hechtman,
Jeffery Epstein, William E. Pelham, Howard B. Abikoff, Jeffrey H.
Newcorn, Brooke S.G. Molina, Stephen P. Hinshaw, Karen C.Wells, Betsy
Hoza, Peter S. Jensen, Robert D. Gibbons, Kwan Hur, Annamarie Stehli,
Mark Davies, John S. March, C. Keith Conners, Mark Caron, Nora D.
Volkow, for the MTA Collaborative Group
Delinquent Behavior and Emerging Substance Use in the MTA at 36-
Months:
Prevalence, Course, and Treatment Effects. Brooke S. G. Molina, Kate
Flory, Stephen P. Hinshaw, Andrew R. Greiner, L. Eugene Arnold, James
M.
Swanson, Lily Hechtman, Peter S. Jensen, Benedetto Vitiello, Betsy
Hoza,
William E. Pelham, Glen R. Elliott, Karen C. Wells, Howard B. Abikoff,
Robert D. Gibbons, Sue Marcus, C. Keith Conners, Jeffery N. Epstein,
Laurence L. Greenhill, John S. March, Jeffrey H. Newcorn, Joanne B.
Severe, Timothy Wigal, and the MTA Cooperative Group. The Office of
Special Education Programs of the U.S. Department of Education, the
Office of Juvenile Justice and Delinquency Prevention of the Justice
Department, and the National Institute on Drug Abuse (NIDA) also
participated in funding this study.