Volume 189 - Issue 5
In the long run, skills are as good as pills for attention deficit hyperactivity disorder
Authors: Alison Poulton and Ralph K H Nanan
Med J Aust 2008; 189 (5): 295-296. || doi: 10.5694/j.1326-5377.2008.tb02038.x
Published online: 1 September 2008
Published online: 1 September 2008
To the Editor: We read with interest Rey’s interpretation of the Multimodal Treatment Study of Children with Attention Deficit Hyperactivity Disorder (MTA).1 The MTA was a large randomised study comparing the impact of stimulant medication, behavioural treatment, a combination of the two, and standard community care on attention deficit hyperactivity disorder (ADHD).2 The treatment phase lasted 14 months, during which the children taking medication showed more improvement than the other groups. Participants were then allowed to change their treatment and, at 36-month follow-up, the outcomes in all groups were similar. Rey concluded that, if stimulant medication is not associated with sustained improvement, its place in the treatment of ADHD is limited.
This conclusion overlooks two important points. First, the greater initial improvement in symptoms of ADHD associated with stimulant medication might be important both clinically and socially. The second point is the expected impact of a relatively brief intervention: is it really plausible that an independent effect of 14 months of controlled treatment will be detectable after a further 22 months of self-selected management? The observation that the 14-month treatment phase becomes progressively less relevant as time passes is perhaps not altogether unexpected.
In the unmedicated group, the 23% non-compliance rate during the 14-month treatment phase indicated greater dissatisfaction with treatment than the 10% non-compliance in the medication groups (P < 0.005, χ2 test). This could imply a parental preference for more immediate relief of symptoms, even if it involves their child taking medication. Parental preference can be accommodated if the family and treating physician discuss and agree on a treatment plan, adjusted to optimise functioning. Far from indicating a diminished role for medication, the evidence from the MTA study suggests that the clinical approach would involve most individuals with ADHD being treated with stimulant medication at some stage.
Stimulant medication treats symptoms; it is not curative. It is likely that the role of stimulant medication in the treatment of ADHD decreases as children mature. However, temporary relief of symptoms can be highly valuable for affected children and their families.
References
- Rey JM. In the long run, skills are as good as pills for attention deficit hyperactivity disorder [editorial]. Med J Aust 2008; 188: 133-132. 0_CBBIEAGC
- Jensen PS, Arnold LE, Swanson JM, et al. 3-year follow-up of the NIMH MTA study. J Am Acad Child Adolesc Psychiatry 2007; 46: 989-1002. 0_CBBGEJHC