The controversial subject of medicating children with ADHD was the focus of several APA 2001 Annual Convention sessions.
Among the experts in the area is Gretchen LeFever, PhD, of Eastern Virginia Medical School–one of the few researchers systematically collecting epidemiological data on the extent of medication use for ADHD. LeFever asserts that the amount of drug treatment outpaces ADHD’s prevalence.
To support her view, she pointed to a study in which she compared ADHD medication rates in Virginia with several other states to generate a national picture of ADHD drug treatment. School records from two Virginia school districts alone revealed that the rate of ADHD drug treatment was two to three times higher than the national estimates for the disorder.
In her study, LeFever found that 84 percent of children with ADHD received medication at some point in time, and 70 percent were receiving it at the time of the survey. The only children who had never received drug treatment were uninsured, she found.
In addition, 28 percent of the elementary school students who were medicated for ADHD in LeFever’s study received two or more psychotropic drugs simultaneously. For many of them, treatment began during preschool or early childhood years.
To reduce rates of medication, LeFever called for “a public health agenda that includes improved systems for tracking ADHD diagnoses, treatments and outcomes and primary prevention initiatives.”
Taking a different tack, Columbia University’s Peter Jensen, MD, presented data to disprove that behavioral therapy–even the most intensive parental training and teacher consultation–manages ADHD as effectively as medication.
Jensen cited the NIMH Collaborative Multisite Multimodal Treatment Study of Children With Attention-Deficit/Hyperactivity Disorder (MTA), of which he, presenter William Pelham, PhD, of the State University of New York at Buffalo and six others were lead investigators.
The study tested four treatment options–combined pharmacological and intensive behavioral therapy, medicine alone, intensive behavioral therapy alone and “usual care,” leaving families with the choice of treatment they would seek from their community providers. This option thus included medication with methylphenidate for 70 percent of the cases.
Jensen reported that the researchers found children’s inattention and hyperactivity could be equitably managed with both intensive combination and pharmacological treatments, but that combined treatments more successfully treated “domains of functional impairment” such as aggression, defiance and poor social skills than medication alone.
At the end of his year-long study, Jensen reported, 68 percent of participants in the combined group met the criteria for ADHD normalization–a reduction or complete discontinuation of the behaviors, such as extreme aggression and lack of concentration, that set ADHD children apart from their peers. In the medication management group 56 percent met normalization criteria, in the behavior therapy group 34 percent reached normalization and only 25 in the community-care groups did likewise.
But as the percentages reveal, medication is not the only effective nor always the best treatment option for every child.
Pelham, who chaired the panel, also reported on the parent and teacher satisfaction with treatments in the MTA study and shared their one-year follow-up data. He pointed out that children treated with behavioral methods had shown dramatic improvement regardless of the fact that those who remained actively medicated were functioning better in terms of ADHD symptoms. However, the nature of the intervention produced dramatically different results for satisfaction with treatment: With medication alone there was a much higher rate of dropout from the treatment and much greater parent and teacher dissatisfaction with the results, in addition to a significantly lower rate of very positive satisfaction.
By comparison, parents and teachers much preferred a combination of pharmacological and behavioral treatment and behavioral treatment alone. These options had far lower dropout rates and much lower dissatisfaction, and also appeared to produce results with more staying power after one year of treatment.
These results are important, according to Pelham, because they reveal that “ADHD is a chronic disorder that requires chronic treatment, and interventions must be palatable to parents and teachers in order for them to continue over the long haul,” he said.
“Parents need to be presented with a choice,” he said, concerned that, in actual practice, the risks and benefits of medication are rarely presented. Wider treatment options, he said, “will help normalize functioning of many ADHD children without medication.
O’Connor, E. (2001). “Medicating ADHD: Too Much? Too Soon?” American Psychological Association. Vol. 32. No. 11. Pg. 50. Monitor Staff.