In brief

The Treatment of Attention Deficit Disorder: New Evidence

Another long-term, large-scale clinical trial has found disappointing results from the psychosocial treatment of attention deficit hyperactivity disorder. In the two-year study, described in a series of articles in the Journal of the American Academy of Child and Adolescent Psychiatry, the subjects were 103 children ages 7 – 9 with the typical symptoms of distractibility, hyperactivity, and impulsiveness. More than half were also diagnosed with oppositional defiant disorder — ill-tempered, disobedient, annoying, and easily annoyed.

The children were divided into three groups. One-third received the stimulant drug methylphenidate (Ritalin) alone, and one-third were given the drug along with intensive behavioral therapy, academic assistance, and parent training. The rest received the drug plus an “attention control” consisting of play groups.

The psychosocial treatment included individual psychotherapy, social skills training, and help with schoolwork and reading. Parents were given advice and training in how to cope with the symptoms. Using videotapes, homework assignments, and other methods, therapists tried to teach the children social skills — for example, how to wait their turn, cooperate in groups, and conduct conversations without interrupting. Child psychiatrists, parents, teachers, and the children themselves judged the outcome.

About 80% of the children in each of the three groups completed the trial, and all three groups improved equally, whether the outcome was judged by academic tests, teachers’ and parents’ behavior ratings, or the children’s own reports on depression and self-esteem. None of the psychosocial treatments made any difference, either for the group as a whole or for children with oppositional defiant disorder.

After a year, all the children were switched from the drug to a placebo and given the drug again only if they seemed to need it. For those who continued to take the drug, its benefits lasted throughout the two years. The number who were able to stop taking it after a year was the same in all three groups.

The authors point out that they used many sources of information and conducted a careful statistical analysis in their effort to find some good results. The parents and teachers were participating, knew about the treatment, and must have been hopeful. Nevertheless, there was no evidence that long-term psychosocial treatment in addition to Ritalin was more effective than the drug alone for the treatment of either attention deficit hyperactivity disorder or oppositional defiant disorder.

An earlier trial, the Multimodal Treatment Study, sponsored by the National Institute of Mental Health, gave similar results for a larger number of children over a briefer time — 14 rather than 24 months. In that study, school aides provided behavioral treatments and helped teachers with classroom management. If there is a provably effective psychosocial treatment, it has not been found yet. But as long as medications don’t work for all and the dropout rate in stimulant treatment remains high, researchers will undoubtedly keep looking.

Klein RG, et al. “Design and Rationale of Controlled Study of Long-Term Methylphenidate and Multimodal Psychosocial Treatment in Children with ADHD,” Journal of the American Academy of Child and Adolescent Psychiatry (July 2004): Vol. 43, No. 7, pp. 792 – 801.

Abikoff H, et al. “Symptomatic Improvement in Children with ADHD Treated with Long-Term Methylphenidate and Multimodal Psychosocial Treatment,” Journal of the American Academy of Child and Adolescent Psychiatry (July 2004): Vol. 43, No. 7, pp. 802 – 11.

Hechtman L, et al. “Academic Achievement and Emotional Status of Children with ADHD Treated with Long-Term Methylphenidate and Multimodal Psychosocial Treatment,” Journal of the American Academy of Child and Adolescent Psychiatry (July 2004): Vol. 43, No. 7, pp. 812 – 19.

Abikoff H, et al. “Social Functioning in Children with ADHD Treated with Long-Term Methylphenidate and Multimodal Psychosocial Treatment,” Journal of the American Academy of Child and Adolescent Psychiatry (July 2004): Vol. 43, No. 7, pp. 820 – 29.