Evidence has supported three interventions for children with ADHD: behavioural therapy, pharmacotherapy and a combination of both. However, there are still some questions as to how to effectively implement combined treatment approaches as a means to provide long-term outcomes for children with ADHD.
In 1990, the National Institute of Mental Health (NIMH) determined that: (1) ADHD was a major public health problem for children; (2) literature supported medication and behavioural therapy as treatment for ADHD; and (3) there was accumulating evidence for combining both treatments and a multi-site study comparing these interventions was needed. Shortly afterwards, the NIMH Multimodal Treatment for ADHD (MTA) study was initiated to compare the effectiveness of a behavioural intervention,* stimulant intervention† and a combination‡ of both in children with ADHD (n=576; age range 7‒9.9 years) versus a community-treated comparison group§ in school and home settings over the course of 1 year. All treatments were stopped at the 14-month study endpoint and parents could choose for their child to maintain treatment. Periodic follow-up over several years in the form of phone calls and visits enquired about continuing treatment, symptoms and functioning.
Results from initial studies of the MTA study showed that:
- For parent- and teacher-rated ADHD symptoms at 14 months, the stimulant intervention group and the combined intervention group were comparable, and were superior to both the behavioural intervention group and the community-treated comparison group at home and school.
- In terms of functional outcomes, the behavioural intervention was equivalent or superior to the stimulant intervention group; however, the combined intervention group produced the best results overall.
Data from later studies of the MTA study indicated that:
- One year after the study had ended, half of the incremental benefit of stimulant medication was lost, and all benefit was lost 2 years later compared with the behavioural intervention.
- At the 8-year follow-up, there was no reported differential benefit among the treatment interventions, apart from a reduction in height in children who received stimulant medication (also noted at the 16-year follow-up).
The data from the MTA study suggested that a combined treatment approach for ADHD had a larger beneficial impact in the short term for both symptoms and functional impairments associated with ADHD. Beyond the MTA study, the authors highlighted that studies into the combined approach to manage ADHD suggested that:
- Behavioural interventions should be implemented before initiation of medication.
- For maximum and long-term efficacy, the psychological (i.e. behavioural and/or academic) components of treatment should be provided before medication is prescribed. By doing so, this teaches skills to address functional impairments associated with ADHD such as parenting, school functioning and peer relationships.
In the authors’ opinion, beginning with a psychosocial-first approach to manage ADHD enables lower doses of medication to be used compared with medication-only treatment, and consequently leads to lower short- and long-term side effects and reduced healthcare costs. In addition, by using a combined treatment approach, the burden of behavioural treatment on parents and teachers is lessened and thereby enhances the likelihood that these interventions will continue to be used over time. The authors indicated that although the MTA study demonstrated that there was no residual benefit of stimulation-only treatment, no information was available as to whether combined treatments were continued and had lasting benefits. Therefore, the authors suggested that a large-scale trial to assess the long-term effects of a combined treatment approach for children with ADHD is warranted.
*Included 35 sessions of individual and small-group parent behavioural training, an intensive comprehensive 8-week summer treatment programme, a behavioural classroom intervention consisting of a half-time aide for a school semester with an aide-implemented classroom management programme, 14 sessions of teacher consultation on classroom behaviour management and a teacher-administered daily home report card
†Involved a 4-week titration of short-acting methylphenidate 5, 10 and 15/20 mg three times per day (one in the morning, one in the afternoon and one late-afternoon half dose delivered 7 days per week). Following titration, medication doses were assigned and adjusted upward as needed in monthly medication visits to the maximum tolerable dose in both the combined and medication-only treatment groups. The mean daily dose of methylphenidate was 38 mg in 2.5 doses. Compared with extended-release stimulant regimens, this was equivalent to 54 mg every morning of the 12-hour versions of methylphenidate in current use
‡Identical to the individual treatment groups, except that the behavioural therapists were given 3 weeks to adjust the behavioural programme in a month when ratings indicated more treatment was required. In this group, the mean dose of methylphenidate was 25% less than the stimulant intervention group, suggesting that the addition of behavioural therapy reduced the need for extra medication
§Received community-based treatments; among this group, almost 70% received stimulants from their own physician
Pelham WE Jr, Altszuler AR. Combined treatment for children with attention-deficit/hyperactivity disorder: brief history, the multimodal treatment for attention-deficit/hyperactivity disorder study, and the past 20 years of research. J Dev Behav Pediatr 2020; 41(Suppl 2S): S88-S98.