3-year follow-up of the NIMH MTA study

Child and adolescent mental health policy: promise to provision

Mental health policy enables the translation of the knowledge base of 'how' to help children and families into the actual 'provision' of help. Amid competing pressures to leave the allocation of services to the market, policy is required to define needs, select priorities, match resources with need, and to measure what has been accomplished. Crafting policy requires balancing contrasting goals and approaches, here spelled out. Public mental health policy can be compared to other forms of continuous quality improvement (CQI).

Gender differences in ADHD: implications for psychosocial treatments

Attention-deficit/hyperactivity disorder (ADHD) has now been recognized to exist in both males and females, albeit the literature supports a higher prevalence in males. However, when girls are diagnosed with ADHD, they are more often diagnosed as predominantly inattentive than boys with ADHD. This paper provides a review of gender differences noted across the lifespan in terms of psychosocial functioning, cognitive abilities and psychiatric comorbidities. Males and females with ADHD are more similar than different, and generally symptoms of ADHD are not sex specific. Small gender differences have been found: adolescent girls with ADHD have lower self-efficacy and poorer coping strategies than adolescent boys with ADHD, but these differences tend to disappear by adulthood; rates of depression and anxiety may be higher (especially in adolescence) while physical aggression and other externalizing behaviors may be lower in girls and women with ADHD, although not all studies support these findings (e.g., non-referred samples show similar rates of coexisting psychiatric disorders between boys and girls with ADHD). However, many studies suffer from small sample sizes, referral biases, differences in diagnostic procedures and possible rater influences. Psychosocial treatments are reviewed and discussed with reference to the reported gender differences in functioning as well as the global deficits noted in all samples. Although the data available so far suggest that psychosocial treatments are likely to be equally effective in males and females, this conclusion is based more on the small number of gender differences noted in overall functioning and less on empirical research on treatment by sex effects and the moderating role of sex, an effect only investigated by the Multi-modal Treatment Study of ADHD group, to date. Future research should include equal representation of both sexes in samples such that treatment analyses by gender can be routinely conducted.

Research forum on psychological treatment of adults with ADHD

BACKGROUND

A literature search found five empirical studies of psychological treatment for adults with ADHD, out of 1,419 articles on ADHD in adults. Practice guidelines to date all recommend multimodal intervention, given that a significant number of patients cannot tolerate, do not respond to, or fail to reach optimal outcomes with medication alone.

METHOD

This article provides a literature review and the recommendations of a forum of experts in the psychological treatment of adults with ADHD.

RESULTS

Empirical studies of brief, structured, and short-term psychological interventions for adults with ADHD to date demonstrate moderate to large effect sizes. Methodological challenges include selection of control groups, broad-based measures of outcome, and the need for larger samples.

CONCLUSION

Psychological treatment may play a critical role in the management of adults with ADHD who are motivated and developmentally ready to acquire new skills as symptoms remit.

Parental attitudes and involvement in psychopharmacological treatment for ADHD: a conceptual model

Current evidence strongly points to significant parental concerns about exposing their children to psychopharmacological medications. This is true even with stimulant medications for attention deficit/hyperactivity disorder (ADHD), an evidence-based treatment for children. Theory and prior evidence would predict that parents' hesitancy to give their children psychopharmacological medication is likely due to what they hear from family and friends about medication's untoward effects. That social networks impact problem definition, treatment evaluation, and service use is well established. However, it is not known how parents make treatment decisions as they cope with the reality that their child might benefit from psychopharmacological medication. The qualitative research described in this paper addresses this gap. A conceptual model is presented that describes parents' treatment decisions and participation in their children's care as they shift from parenting a child with behavioural problems to parenting a child who eventually requires psychopharmacological medication. Further research is needed to evaluate how this model can offer a more comprehensive understanding of how parents respond to a diagnostic label and various treatment options. It is hoped that this research will stimulate innovative approaches for tailoring treatments that are respectful of the individual needs of children and their families.

Psychopharmacological interventions

Currently stimulants and atomoxetine are the most established treatments for attention deficit hyperactivity disorder (ADHD); more than 170 controlled studies with more than 9000 subjects have documented their efficacy in 50% to 70% of subjects. Although the stimulant medications tend to show a dose-related improvement in ADHD symptoms, atomoxetine is generally dosed based on weight. The literature clearly documents that stimulants improve not only abnormal behaviors of ADHD but also self-esteem, cognition, and social and family functioning. However, efficacy varies with age and psychiatric comorbidities. Although most of the existing studies are brief, an increasing number of long-term studies have documented persistent response up to 1 and 2 years. Recent studies are extending the knowledge of treatment to younger and older subjects, women, and ethnic minorities. Cognitive and cognitive/behaviorally based psychotherapies combined with medication may play a role in treating behavioral and organizational issues and comorbid psychopathology.

Epidemiologic considerations in attention deficit hyperactivity disorder: a review and update

Epidemiologic data on attention deficit hyperactivity disorder (ADHD) are essential for planning health services and implementing strategies of detection and early intervention, with possible substantial benefits on public health. This article addresses methodological aspects of prevalence studies, recent findings on the prevalence of ADHD in childhood and adolescence based on a systematic review, current findings on the persistence of the disorder over time and prevalence in adulthood, and factors associated with ADHD. Evidence from the reviewed literature indicates the importance of methodological aspects in the understanding of epidemiologic findings and the necessity of large-scale cross-national studies. Moreover, governments clearly must direct attention to childhood mental disorders to guarantee a healthy future for their countries.

Effects of stimulant medication on growth rates across 3 years in the MTA follow-up

OBJECTIVE

To evaluate the hypothesis of stimulant medication effect on physical growth in the follow-up phase of the Multimodal Treatment Study of Children With ADHD.

METHOD

Naturalistic subgroups were established based on patterns of treatment with stimulant medication at baseline, 14-, 24-, and 36-month assessments: not medicated (n = 65), newly medicated (n = 88), consistently medicated (n = 70), and inconsistently medicated (n = 147). Analysis of variance was used to evaluate effects of subgroup and assessment time on measures of relative size (z scores) obtained from growth norms.

RESULTS

The subgroup x assessment time interaction was significant for z height (p <.005) and z weight (p <.0001), due primarily to divergence of the newly medicated and the not medicated subgroups. These initially stimulant-naïve subgroups had z scores significantly >0 at baseline. The newly medicated subgroup showed decreases in relative size that reached asymptotes by the 36-month assessment, when this group showed average growth of 2.0 cm and 2.7 kg less than the not medicated subgroup, which showed slight increases in relative size.

CONCLUSIONS

Stimulant-naïve school-age children with Combined type attention-deficit/hyperactivity disorder were, as a group, larger than expected from norms before treatment but show stimulant-related decreases in growth rates after initiation of treatment, which appeared to reach asymptotes within 3 years without evidence of growth rebound.

Delinquent behavior and emerging substance use in the MTA at 36 months: prevalence, course, and treatment effects

OBJECTIVE

To compare delinquent behavior and early substance use between the children in the Multimodal Treatment Study of Children With ADHD (MTA; N = 487) and those in a local normative comparison group (n = 272) at 24 and 36 months postrandomization and to test whether these outcomes were predicted by the randomly assigned treatments and subsequent self-selected prescribed medications.

METHOD

Most MTA children were 11 to 13 years old by 36 months. Delinquency seriousness was coded ordinally from multiple measures/reporters; child-reported substance use was binary.

RESULTS

Relative to local normative comparison group, MTA children had significantly higher rates of delinquency (e.g., 27.1% vs. 7.4% at 36 months; p = .000) and substance use (e.g., 17.4% vs. 7.8% at 36 months; p = .001). Children randomized to intensive behavior therapy reported less 24-month substance use than other MTA children (p = .02). Random effects ordinal growth models revealed no other effects of initial treatment assignment on delinquency seriousness or substance use. By 24 and 36 months, more days of prescribed medication were associated with more serious delinquency but not substance use.

CONCLUSIONS

Cause-and-effect relationships between medication treatment and delinquency are unclear; the absence of associations between medication treatment and substance use needs to be re-evaluated at older ages. Findings underscore the need for continuous monitoring of these outcomes as children with attention-deficit/hyperactivity disorder enter adolescence.

Secondary evaluations of MTA 36-month outcomes: propensity score and growth mixture model analyses

OBJECTIVE

To evaluate two hypotheses: that self-selection bias contributed to lack of medication advantage at the 36-month assessment of the Multimodal Treatment Study of Children With ADHD (MTA) and that overall improvement over time obscured treatment effects in subgroups with different outcome trajectories.

METHOD

Propensity score analyses, using baseline characteristics and severity of attention-deficit/hyperactivity disorder symptoms at follow-up, established five subgroups (quintiles) based on tendency to take medication at the 36-month assessment. Growth mixture model (GMM) analyses were performed to identify subgroups (classes) with different patterns of outcome over time.

RESULTS

All five propensity subgroups showed initial advantage of medication that disappeared by the 36-month assessment. GMM analyses identified heterogeneity of trajectories over time and three classes: class 1 (34% of the MTA sample) with initial small improvement followed by gradual improvement that produced significant medication effects; class 2 (52%) with initial large improvement maintained for 3 years and overrepresentation of cases treated with the MTA Medication Algorithm; and class 3 (14%) with initial large improvement followed by deterioration.

CONCLUSIONS

We failed to confirm the self-selection hypothesis. We found suggestive evidence of residual but not current benefits of assigned medication in class 2 and small current benefits of actual treatment with medication in class 1.