The MTA Study and ADHD

In 1999, the National Institute of Mental Health sponsored the most comprehensive study of ADHD children that had ever been done. They wanted to find out how various treatment approaches compared in outcome. It was called the Multimodal Treatment Study of ADHD (MTA). 579 children ages 7-9 with ADHD combined type were studied for 14 months. Patients were randomly assigned to one of 4 groups: A) Referred to doctors in the community for treatment as usual B) Treated with stimulants or placebo* according to strict dosing guidelines and frequent dose adjustments during the first four weeks. They also had daily feedback from the child’s parents and teachers. The children were first given methylphenidate (generic Ritalin) and then if not doing well changed to Dexedrine or one of 2 other medicines. After the first 4 weeks they were followed monthly. C) Comprehensive cognitive/behavioral treatment that included individual, group, and family therapy, aides in the classroom and summer camps. D) Combination of B and C *stimulants or placebo under blinded conditions Response rates were positive in 77% of the patients on medication. Cognitive behavioral treatment (CBT) added to medication did not provide any additional benefits to the medication alone. Benefits were noted even more in school than at home. Benefits continued throughout the 14 months but quickly reverted back to initial ADHD symptoms when medication stopped. Side effects were mild or none in 86%, moderate in 11%, and only a significant problem in 3%. (Irritability was worse in kids on placebo than medication). CBT did not significantly improve core ADHD symptoms, but did help with anxiety. Patients also on anxiety medication required slightly lower doses of ADHD medication. The MTA study very effectively demonstrated several principles about the treatment of ADHD: 1) Medication works well. Cognitive behavioral therapy alone doesn’t. 2) Patients respond well to the "right medication" at the "right dose." Most reports of bad reactions to stimulants were kids taking the wrong stimulant or the wrong dose. In this study only 3% had significantly negative reactions. 3) Benefits of medication were confirmed throughout 14 months (longer in other studies) without tolerance or sensitization. Three other long duration studies, two in the U.S., and one in Canada, had the same outcome. Other studies have shown continued benefit up to 10 years. Behavioral modification studies have shown some temporary benefit to some symptoms, but as soon as the treatment stops the symptoms return. ADHD is NOT the result of bad parenting. An observational study by Russell Barkley, a leading researcher and expert on ADHD, found that in ADHD families parents are more critical and controlling and less supportive than non ADHD families. However, when medication is given to the ADHD kids the parent’s behavior normalizes. In conclusion, ADHD is a disorder associated with different genetics, differences in brain structures and differences in brain chemistry. Abusive/traumatic childhoods can make it worse, as can excessive exposure to TV or computer games especially at an early age. In my clinical experience of over 30 years when I explain the medical basis of ADHD to kids, teens, and adults and we find the right medication and the right dose of medication, they like taking it. It makes their life easier. They are able to be normal – to pay attention in class, complete reading assignments and other homework, and get along with friends, teachers and family. As a consequence their self-esteem and self-confidence improve. The diagnostic tests and treatments recommended on the Dr. Phil Show by Dr. Phil and Dr. Lawlis are not based on scientific evidence. The treatments they criticize are supported by more scientific evidence than most illnesses in all of medicine. The worst thing is that potentially millions of people who have faith in Dr. Phil may rule out the use of medication for their kids and risk adverse outcomes not just to their academics but social skills and self-esteem……but the ratings are good. See ADHD Newsletter