Stimulant drugs like Ritalin that are used to treat ADHD don't improve children's symptoms long term, according to new research published online in the Journal of the American Academy of Child and Adolescent Psychiatry. That may come as a surprise to parents, but ADHD researchers have been arguing for the past 10 years over the findings of the Multimodal Treatment Study of Children with ADHD. Called the MTA study, it is the largest study conducted to compare the benefits of medication to behavioral interventions.
This latest report from the MTA study tracked 485 children for eight years and found those still taking stimulant medication fared no better in the reduction of symptoms such as inattention and hyperactivity or in social functioning than those who hadn't. Most of the children who had taken medication for the first 14 months were no longer taking it. This, the researchers wrote, raises "questions about whether medication treatment beyond two years continues to be beneficial or needed at all." Earlier reports found that children taking stimulants alone or combined with behavioral treatment did better in the first year than children who got no special care or who got behavioral treatment alone.
There's more: Stimulant drugs stunt children's growth, according to another report in the journal that analyzes MTA data. Children who never took stimulants were three quarters of an inch taller and 6 pounds heavier on average than children who took medication for three years. The children don't make up for that later on.
What's a parent to do with this new information? To find out, I talked with William Pelham, a pioneer in the study of behavioral treatments for ADHD and one of many researchers who participated in the MTA study. Pelham is a distinguished professor of psychology at the University of Buffalo. Here's an edited version of our conversation:
You have long been critical of earlier interpretations of the MTA study, which said that stimulant drugs were better at relieving ADHD symptoms than behavioral treatment. Why is that?
The investigators in the study have not owned up to the fact that the results at one year were dramatically different than the results at all the follow-ups. The group has continued to state the usefulness of long-term treatment, when the data show very clearly that it did not help.
If you put a child on medication, he or she is far better right at that time. The question for parents is: Is this going to make a benefit for my child long term? The answer is no. Behavioral treatments are going to have much better benefit in the long term. Unfortunately, we don't have studies of the long-term effects of behavioral therapies eight years out, because they're much harder to do. But theoretically, we know they work.
It's easy to find a doctor who will prescribe Ritalin. But many parents feel it's hard to find good behavioral interventions for ADHD.
It's true that it's harder to find than medication. But it's not true that it can't be found. Behavioral parent training is widely available—it is not rocket science, and it's proven to help. School-based interventions for ADHD are also widely available. Almost every teacher in the country knows good behavior management techniques for children with ADHD. What's not as available are the intensive peer programs, which is what we do. We developed an intensive summer program that has the best supported evidence of any program. That's been replicated in a number of places, including New York University, the Cleveland Clinic, and the University of Alabama-Birmingham. It's not as widely available as it should be. But it's wrong for a doctor to say to a parent, this treatment is harder to find, so instead we're going to put your child on a drug that will have no long-term benefit.
Families often have a hard time paying for behavioral therapies. Is that true with ADHD?
Many insurers do not include coverage for psychosocial treatments for ADHD in their plans. They won't pay for the types of interventions that are most evidence-based. That's a problem; that's a public health problem that people at the state and national level need to work on. If Blue Cross Blue Shield paid for behavioral parent training, I assure you it would be everywhere. It's also true for Medicaid. There are many states where Medicaid won't pay for this, even though it's the most solidly evidence-based treatment of all childhood behavioral disorders.
The Institute of Medicine just came out with a report saying that many of these behavioral interventions can actually prevent problems. Can you give me an example?
There's the good behavior game, a very common classroom management tool [in which the class is rewarded for good behavior] that is used for kids with ADHD. If that was used around the country, not only would it be good prevention for behavioral problems generally, it would treat ADHD. We're using the Good Behavior Game in one of our studies.
Another example is the Positive Parenting Program, which is one of 10 really good evidence-based behavioral parent-training programs.
The IOM has not argued to put Ritalin in the water as a prevention. They're recommending taking the effective psychosocial things we know work and making them widely available. If that happened, there would be much less need to medicate ADHD kids.
Here's a story I wrote last fall about nondrug treatments for ADHD, which includes more information on the controversy surrounding the MTA study. Here's information on how to find a great ADHD summer camp for your child. And here's more on how parenting classes and classroom programs can prevent mental illness in kids.