ADHD Drugs Not Better than Psychotherapy After Three Years
This has been knocked around in the blogosphere after an article in the Washingon Post publicized this week’s study results, however I thought I would give the study my usual thorough going over. The ongoing NIH funded Multi-site Multimodality Treatment of Attention Deficit Hyperactivity Disorder (MTA) study (updated in an article this week in the Journal of the American Academy of Child & Adolescent Psychiatry) showed that treatment with the stimulant medication Ritalin (methylphenidate) wasn’t any better than behavioral treatment after three years. As the parent of a child diagnosed with ADD who struggled for two years trying to cope on our own, going through hell for another two years with medications and their nightmare side effects (described in my book using a pseudonym) I sure would have liked to have known about these results (he’s off meds now and doing well), or in fact that behavioral treatment has been shown to be effective (I honestly didn’t know until today– blame myself). Thanks, National Institute of Health (NIH), for issuing a press release when these study results first came out in 2007 and glossing over the results by describing a “remarkable improvement in all groups” while euphemistically describing the result that Ritalin knocked an inch off of kids growth by stating that kids treated with behavioral treatment were “somewhat larger”.
Humph.
Anyhoo back to the study. Children received either Ritalin or behavioral treatment or a combination of both, or received “regular care” or community care, administered in a placebo controlled randomized study design. Behavioral treatment involved 27 group parent sessions, 8 individual parent sessions, an eight week summer treatment program, 12 weeks of classroom behavioral therapy, and 10 teacher consultation sessions. At one year Ritalin or combination worked better than behavioral treatment, a result that was much trumpeted by the study authors. After one year patients were followed for another two years without controlled treatment. Although some kids went off drugs and some originally treated with behavioral therapy went on drugs, at the two and three year followup there were still more kids on medication in the original medication treated group than in the behavioral therapy group.
The result? Children who were originally treated with medication did no better than those treated originally with behavioral treatment at three years after the original start of treatment.
_____ Community Care ..... Meds __ __ __ Combo __ .. __ .. Behavioral Rx ____ ____ Normal
What’s interesting about this study that was not noticed in the press coverage is that based on the study results it isn’t clear if any kind of treatment is better than just leaving the kids alone for a couple of years. It’s hard to know though because the “community care” group also got treated with various medications and psychotherapies, but we really don’t know which ones.
Another thing is that by doing a press release that put a positive spin on the results borderlines on fraud. Back in 2007 the authors wrote that there was a “remarkable improvement in all the treatment groups” which glossed over the fact that the study showed that medications were not better than behavioral treatment after three years. Even now when one of the study authors, William E. Pelhem MD, stated the obvious conclusion that medications are no different than behavioral treatment after three years, he was accused by co-author Peter S. Jensen MD of being “biased against medications”. Here is a quote of Dr. Jensen, read and make your own judgment:
Jensen said Pelham was the only member of the team of researchers who took away “the silly message” that the study raised questions about the long-term utility of drugs.
Back in 2007 in the NIH press release Jensen made the following absurd comment:
Our results suggest that medication can make a long-term difference for some children if it’s continued with optimal intensity, and not started or added too late in a child’s clinical course.
What’s with these guys, anyway?
I say why does the Washington Post feel the need to get expert opinions? Look at the graph and decide for yourself. There is NO DIFFERENCE.
That said this study was a really goofy study design, one year of randomized treatment followed by two years of letting people drift. The only explanation for how they came up with such a goofy study design is that they were going with Harvard’s Joseph Biederman’s pronouncements that ADHD is a chronic condition which never gets better (which obviously isn’t true. I had to bite my lip the other day when our pediatrician sat there and told us that ADHD was a permanent condition and if our son was doing well now off meds that he would probably need to take meds again next year if his class wasn’t as interesting. Grrr.) and that treatment gains at one year would hold up at three years (which they didn’t). They must have been surprised at the findings and came up with all kinds of goofy explanations and press releases and stuff and then were relieved when they got away with it. I know that if I had read the paper in 2007 (I didn’t) I wouldn’t have let them get away with that. I don’t know if this study tells us that much, other than that giving your kids Ritalin at age 9 for a year won’t make a difference when he’s 12 over doing behavioral treatment. Looking at this data I was starting to wonder if behavioral treatment was worth the effort or whether kids just got better on their own, however I found this study by Pelham et al 2005 that showed that intensive behavioral treatments were better than doing nothing. I just wish someone had told me that such treatments were useful. I guess that’s what I get for putting my faith in pediatricians and child psychiatrists. It’s all drugs, drugs, drugs.
Another thing is that letting authors say things like “all treatment groups showed a remarkable improvement” rather than “the medication treatment group was no better than the other groups” made me wonder who was responsible for allowing this rot to get published. The current study, the 2007 study, and the infamous Study 329 of SSRIs in kids, all share in common publication in, guess what, publication in the Journal of the American Academy of Child & Adolescent Psychiatry. I started to wonder, what is going on here? And so I looked up the editor, who comes from, surprise, the Yale Child Study Center, home of the fun with Doug crowd, and knowing those guys, the appointment as editor comes more as political payoff than a decision based on merits, which is all the more dissapointing since in this case kids are put at risk.
Maybe we should compare Ritalin to treatment with a wet noodle. Hiyah!
- Pay attention in class!
Hat tip to AHRP blog and Marilyn Mann.
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By Flora, March 30, 2009 @ 9:51 pm
The first sentence of the discussion said:
Intent-to-treat analyses revealed no appreciable differences
among the children based on their randomized treatment group assignment at 7 to
9 years of age.
So they admit to it (even if later they try to conceal it). Did you exaggerate a bit?
F
By Doug Bremner, March 30, 2009 @ 10:42 pm
No but in the press release they say that it is a mistake to conclude that there was no effect of treatment (i.e. medication treatment).
By Therapy Patient, March 31, 2009 @ 12:25 am
Wow! I find it hard to believe that you’d put your son on Ritalin without reading every original paper on the drug. I don’t know the dates, though, so the above paper might postdate you son’s treatment.
This question might be very naive, but I have wondered what effect an intensive exercise program might have on a 9-year-old (or 12-year-old) with ADHD. When I was a kid we used to get so much more physical exercise than kids get now. What if a child runs, or plays basketball, or swims intensively. Would that help the child settle down? My only experience is with dogs, not children, but certain dogs bounce off the walls and calm right down if you run them for 5-10 miles a day. Would that work with kids? I NEVER hear “exercise” as a prescribed activity for ADHD and I keep thinking it might help.
By Gina Pera, April 16, 2009 @ 8:44 pm
Or, maybe we should compare Bill Pelham to a grandstanding, self-serving egotist who would rather be known for his own theories (”which we know work—-theoretically,” he told US News and World Report, in a typical display of bragadoccio — than be lost in the pack of researchers who know that ADHD is real and that the medications are immensely helpful for many people who take them.
Don’t you even stop for a minute and wonder why, of all the researchers, he’s the only one to run to all the news outlets with an angle he knows they’ll fall over themselves picking up? Can’t you see exploitation when you see it?
Researchers’ pharma ties are always questioned. How about questioning Pelham’s pet project, his summer camp for kids with ADHD. How about funding for that? How about selling manuals for that? Or setting up similar camps?
The “media” and some psychiatric pundits’ gullibility for grandstanders like this is extremely worrying. This isn’t a game. Real lives depend on it.
And you’ve misquoted Dr. Biederman, Dr. B. He’s always said that some children do outgrow it, so it’s best to try medication holidays on a regular basis to see.
I just don’t understand why you want to join the bandwagon of those providing misinformation. Don’t understand it at all. And why would you take Pelham’s word for it that behavioral techniques work as well as medication? Why would you not have read more credible experts, such as Russell Barkley, who has long laid out behavioral strategies that work, at least as far as reward-punishment go. (Note: For some people with ADHD, no behavioral strategy in the world is going to help them to listen better, process messages better, eliminate their risk of sleep apnea or restless-legs syndrome or even perhaps diabetes and hypertension, and all the rest.
I understand that the other researchers — who I trust infinitely more than this media gadfly Pelham — will be issuing a press release soon. I hope you will read it closely and present a more balanced view next time.
As for Therapy Patient’s question about exercise, even top ADHD expert and exercise proponent John Ratey, MD, says that if you need ADHD medication, exercise will probably not eliminate the need for it. It can, however, reduce the amount necessary. But again, this is nothing new. Competent practitoners and researchers have long advocated all the things that make and keep humans healthy — exercise, behavioral techniques, good diet and all the rest. It’s only the naysayers who make this into a black/white argument.