Debate about ADHD Multimodal Treatment Study

A recent front-page article from the Washington Post "Debate Over Drugs For ADHD Reignites: Long-Term Benefit For Children at Issue" by Shankar Vedantam examines the 8-year follow-up of the Multimodal Treatment Study of Children With ADHD and the differences of opinion among the study's researchers about what the results might mean.

The study looked at which of three intensive ADHD treatments was best--stimulant medication, behavior therapy, or the combination of both. All three were compared to usual community treatment. The initial results showed a clear superiority of medication (whether alone or combined with behavior therapy) over behavior therapy or community treatment. But when the children were followed-up three years later, medication seemed no better than the other treatments.

A March 26, 2009 press release from the National Institute of Mental Health (NIMH) reviews the pre-publication results of the 8-year-follow-up. The major finding was that the type or intensity of short-term treatment does not affect long-term outcomes. There were no differences in symptoms or functioning among the four original treatment groups. Most of the children who were medicated at 14 months stopped taking medication eight years later but were functioning as well as children who were still medicated.

The debate centers on whether stimulant medication loses its effectiveness after three years. Both sides cite different sophisticated statistical analyses of the same data to support their conclusions. As is often the case, further research is likely needed to settle the debate.

In the meantime, it helps to understand that the intensive treatment phase of the study was only for the first 14 months. After that, children got whatever treatment their parents chose in their own community. As a result, some of the children in the medicated groups stopped taking medication, quite a few in the behavior group started medication, and it turns out that many in the community group were on medication all along (albeit with less intensive management). As a 2007 NIMH press release about the 3-year follow-up notes:
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.
Other results have shown differences in effectiveness and persistence of treatment gains by variables such as gender, income, and the original severity of symptoms. It would seem that just as medication is not the most effective treatment, none of the treatments are equally effective for all children. In fact, the children in each group who had the best response to treatment at 14 months, and again two years later, were doing the best at eight years. As noted in the 2009 NIMH press release:
The researchers also speculate that a child’s initial clinical presentation, including ADHD symptom severity, behavior problems, social skills and family resources, may predict how they will function as teens more so than the type of treatment they received.
Because so many variables are involved, treatment must be individualized for each child. For some, symptoms may be so severe that medication will be more effective in the short-term than behavioral interventions, which take longer to implement. Children with milder symptoms may do fine with only behavior therapy. A combination of treatments is likely to result in the best long-term outcomes for most children. Whichever treatments parents choose, effectiveness must be reviewed periodically and adjusted to meet their children's individual needs.

ResearchBlogging.orgMOLINA, B., HINSHAW, S., SWANSON, J., ARNOLD, L., VITIELLO, B., JENSEN, P., EPSTEIN, J., HOZA, B., HECHTMAN, L., ABIKOFF, H., ELLIOTT, G., GREENHILL, L., NEWCORN, J., WELLS, K., WIGAL, T., GIBBONS, R., HUR, K., & HOUCK, P. (2009). The MTA at 8 Years: Prospective Follow-up of Children Treated for Combined-Type ADHD in a Multisite Study Journal of the American Academy of Child & Adolescent Psychiatry, 48 (5), 484-500 DOI: 10.1097/CHI.0b013e31819c23d0
This post was featured in Grand Rounds, Vol. 5, No. 36 « See First Blog


  1. This is an excellent explanation of the recent publication and should be helpful to parents as well as clients with ADHD. Thank you.

  2. This has been a so interesting read, would love to read more here....

  3. This is really nice info.Thanks for such a wonderful post.


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