A.D.H.D. Experts Re-evaluate Study’s Zeal for Drugs
Ramin Rahimian for The New York Times
Stephen Hinshaw, a University
of California, Berkeley, researcher in an influential 1990s study, said
skills training should be a priority in A.D.H.D. cases.
By ALAN SCHWARZ
Published: December 29, 2013 171 Comments
Twenty years ago, more than a dozen leaders in child psychiatry received $11 million from the National Institute of Mental Health
to study an important question facing families with children with
attention deficit hyperactivity disorder: Is the best long-term
treatment medication, behavioral therapy or both?
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The widely publicized result was not only that medication like Ritalin
or Adderall trounced behavioral therapy, but also that combining the two
did little beyond what medication could do alone. The finding has
become a pillar of pharmaceutical companies’ campaigns to market
A.D.H.D. drugs, and is used by insurance companies and school systems to
argue against therapies that are usually more expensive than pills.
But in retrospect, even some authors of the study — widely considered
the most influential study ever on A.D.H.D. — worry that the results
oversold the benefits of drugs, discouraging important home- and
school-focused therapy and ultimately distorting the debate over the
most effective (and cost-effective) treatments.
The study was structured to emphasize the reduction of impulsivity and
inattention symptoms, for which medication is designed to deliver quick
results, several of the researchers said in recent interviews. Less
emphasis was placed on improving children’s longer-term academic and
social skills, which behavioral therapy addresses by teaching children,
parents and teachers to create less distracting and more organized
learning environments.
Recent papers have also cast doubt on whether medication’s benefits last as long as those from therapy.
“There was lost opportunity to give kids the advantage of both and
develop more resources in schools to support the child — that value was
dismissed,” said Dr. Gene Arnold, a child psychiatrist and professor at Ohio State University and one of the principal researchers on the study, known as the Multimodal Treatment Study of Children With A.D.H.D.
Another co-author, Dr. Lily Hechtman of
McGill University in Montreal, added: “I hope it didn’t do irreparable
damage. The people who pay the price in the end is the kids. That’s the
biggest tragedy in all of this.”
A.D.H.D. narrowly trails asthma as the most frequent long-term medical diagnosis in children. More than 1 in 7 children
in the United States receive a diagnosis of the disorder by the time
they turn 18, according to the Centers for Disease Control and
Prevention. At least 70 percent of those are prescribed stimulant
medication like Adderall or Concerta because, despite potential side
effects like insomnia and appetite suppression, it can quickly mollify
symptoms and can cost an insured family less than $200 a year.
Comprehensive behavioral (also called psychosocial) therapy is used far
less often to treat children with the disorder largely because it is
more time-consuming and expensive. Cost-conscious schools have few aides
to help teachers assist the expanding population of children with the
diagnosis, which in some communities reaches 20 percent of students.
Many insurance plans inadequately cover private or group therapy for
families, which can cost $1,000 a year or more.
“Medication helps a person be receptive to learning new skills and
behaviors,” said Ruth Hughes, a psychologist and the chief executive of
the advocacy group Children and Adults With Attention-Deficit/Hyperactivity Disorder. “But those skills and behaviors don’t magically appear. They have to be taught.”
Accepting no support from the pharmaceutical industry — “to keep it
clean,” Dr. Arnold said — the National Institute of Mental Health
gathered more than a dozen top experts on A.D.H.D. in the mid-1990s to
try to identify the best approach. Over 14 months, almost 600 children
with the disorder ages 7 to 9 across the United States and Canada
received one of four treatments: medication alone, behavioral therapy
alone, the combination, or nothing beyond whatever treatments they were
already receiving.
The study’s primary paper,
published in 1999, concluded that medication “was superior to
behavioral treatment” by a considerable margin — the first time a major
independent study had reached that conclusion. Combining the two, it
said, “did not yield significantly greater benefits than medication”
alone for symptoms of the disorder.
In what became a simple horse race, medication was ushered into the winner’s circle.
“Behavioral therapy alone is not as effective as drugs,” ABC’s “World
News Now” reported. One medical publication said, “Psychosocial
interventions of no benefit even when used with medication.”
Looking back, some study researchers say several factors in the study’s
design and presentation to the public disguised the performance of
psychosocial therapy, which has allowed many doctors, drug companies and
schools to discourage its use.
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