Med­ica­tion treat­ment and behav­ior ther­a­py are both con­sid­ered effec­tive treat­ments for ADHD; the com­bi­na­tion of these treat­ments is gen­er­al­ly regard­ed as an ide­al approach for many chil­dren. How­ev­er, in the Mul­ti­modal Treat­ment Study of ADHD (MTA Study), the largest ADHD treat­ment study ever con­duct­ed, the ben­e­fit of com­bined treat­ment rel­a­tive to med­ica­tion treat­ment alone — while sig­nif­i­cant for some out­come mea­sures — was not espe­cial­ly robust. This has led some pro­fes­sion­als to ques­tion whether behav­ior ther­a­py is nec­es­sary when a child is being effec­tive­ly treat­ed with med­ica­tion, i.e., will behav­ior ther­a­py make a suf­fi­cient dif­fer­ent to be worth­while? (For a review of the ini­tial set of find­ings from the MTA study.

One lim­i­ta­tion of most pri­or stud­ies exam­in­ing com­bined treat­ment — MTA includ­ed — is that the incre­men­tal ben­e­fits of behav­ior ther­a­py have been exam­ined in the con­text of an opti­mized med­ica­tion dose. For exam­ple, each child in the MTA Study began med­ica­tion treat­ment with an inten­sive place­bo-con­trolled tri­al to deter­mine his or her most effec­tive dose. Thus, the ben­e­fits of adding behav­ioral treat­ment to med­ica­tion was eval­u­at­ed in the con­text of an opti­mized med­ica­tion regime. Gen­er­al­ly speak­ing, the incre­men­tal ben­e­fits of behav­ior treat­ment when eval­u­at­ed in this con­text are mod­est at best.

How­ev­er, med­ica­tion treat­ment in com­mu­ni­ty set­tings is rarely deliv­ered in ways to opti­mize ben­e­fits. And, an entire­ly dif­fer­ent but impor­tant ques­tion is whether com­bin­ing behav­ior ther­a­py and med­ica­tion can sig­nif­i­cant­ly reduce the dose of med­ica­tion required to attain effec­tive symp­tom man­age­ment. This would be an impor­tant result because sus­tained stim­u­lant med­ica­tion treat­ment may be asso­ci­at­ed with growth sup­pres­sion. Low­er dos­es may reduce growth sup­pres­sion effects, be asso­ci­at­ed with reduced side effects over­all, and be more palat­able to fam­i­lies con­cerned about med­icat­ing their child.

A study recent­ly pub­lished online in the Jour­nal of Abnor­mal Child Psy­chol­o­gy [Pel­ham et al., (2014). A dose-rang­ing study of behav­ioral and phar­ma­co­log­i­cal treat­ment in social set­tings for chil­dren with ADHD, DOI 10,1007/s10802-013‑9843‑8 ] takes a care­ful look at this impor­tant issue. Par­tic­i­pants were 48 5–12 year-old chil­dren with ADHD who were par­tic­i­pat­ing in an inten­sive sum­mer treat­ment pro­gram (STP). The STP ran for 9 hours/day and last­ed 9 weeks. Chil­dren spent 2 hours each day in aca­d­e­m­ic activ­i­ties and the rest of each day in group recre­ation­al activ­i­ties sim­i­lar to a reg­u­lar sum­mer day camp.

Treat­ments

Med­ica­tion — Dur­ing the STP, chil­dren received 3 dif­fer­ent dose of stim­u­lant med­ica­tion, i.e., low, medi­um and high, along with a place­bo. The med­ica­tion was a short-act­ing methylphenidate (the gener­ic form of rital­in) and was admin­is­tered 3 times each day. Med­ica­tion dose was switched dai­ly and STP staff were blind to what the child received each day.

Behav­ior Ther­a­py — Behav­ior ther­a­py was pro­vid­ed in low inten­si­ty and high inten­si­ty vari­ants. In both cas­es, treat­ment includ­ed a point sys­tem to pro­mote desired behav­ior, clear­ly stat­ed rules and expec­ta­tions, social skills and social prob­lem solv­ing train­ing, social praise and rein­force­ment, ath­let­ic skills train­ing, and the use of dai­ly and week­ly rewards.

The main dif­fer­ence was that in the low inten­si­ty con­di­tion, each ele­ment was mod­i­fied so that it required less effort to pro­vide. For exam­ple, in the high inten­si­ty con­di­tion, chil­dren earned and lost points through­out the day based on their behav­ior. In the low inten­si­ty con­di­tion, chil­dren received feed­back on their behav­ior but did not gain or lose points. Sim­i­lar­ly, although the con­tent of social skills lessons was sim­i­lar, in the low inten­si­ty con­di­tion, social skills feed­back was not incor­po­rat­ed into dai­ly activ­i­ties and social prob­lem solv­ing train­ing was not pro­vid­ed. Rewards for good behav­ior were pro­vid­ed on a week­ly rather than dai­ly basis.

Study Design

The basic design of the study var­ied med­ica­tion dose — place­bo, low, medi­um, high — with behav­ioral treat­ment — none, low inten­si­ty, high inten­si­ty — so that chil­dren’s behav­ior in each treat­ment com­bi­na­tion could be assessed. Thus, each child was eval­u­at­ed dur­ing all pos­si­ble com­bi­na­tions of med­ica­tion dose and behav­ior ther­a­py. This enabled the researchers to deter­mine, for exam­ple, how a low dose of med­ica­tion com­bined with low inten­si­ty behav­ior ther­a­py com­pared to a high dose of med­ica­tion alone.

Out­come mea­sures

Assess­ments of chil­dren’s behav­ior dur­ing each com­bi­na­tion of med­ica­tion and behav­ior ther­a­py was pro­vid­ed by coun­selors. Coun­selors were blind to med­ica­tion sta­tus but, because they deliv­ered the behav­ioral treat­ment, were aware of which behav­ioral con­di­tion the child was in, i.e., no, low inten­si­ty, high inten­si­ty.

The main out­come rat­ing was derived from the dai­ly point sys­tem employed in the STP. Through this sys­tem, dai­ly mea­sures were derived for each child’s lev­el of rule vio­la­tions, non­com­pli­ance, inter­rupt­ing, seri­ous con­duct prob­lems, and neg­a­tive ver­bal­iza­tions. In addi­tion, coun­selors com­plet­ed a dai­ly rat­ing of ADHD symp­toms, over­all degree of impair­ment, and med­ica­tion side effects.

Results

As expect­ed, med­ica­tion treat­ment in the absence of behav­ior mod­i­fi­ca­tion was asso­ci­at­ed with sig­nif­i­cant improve­ments in chil­dren’s behav­ior. And, as dose increased, so did the ben­e­fits — on aver­age — to chil­dren’s behav­ior.

Behav­ior ther­a­py in the absence of med­ica­tion treat­ment was also asso­ci­at­ed with sig­nif­i­cant behav­ioral improve­ment across a wise range of mea­sures. In gen­er­al, high inten­si­ty behav­ior man­age­ment was asso­ci­at­ed with greater behav­ioral improve­ments and ADHD symp­tom reduc­tions than low inten­si­ty behav­ior man­age­ment.

The real­ly inter­est­ing find­ings from this study con­cern the com­bi­na­tion of med­ica­tion and behav­ioral treat­ment. On vir­tu­al­ly all mea­sures, adding high inten­si­ty behav­ior man­age­ment to the low­est med­ica­tion dose of med­ica­tion yield­ed com­pa­ra­ble improve­ments to those pro­duced by the high dose med­ica­tion alone. For a num­ber of mea­sures, even low inten­si­ty behav­ior man­age­ment com­bined with the low­est med­ica­tion dose was as effec­tive as high dose med­ica­tion.

To be con­crete, results sug­gest­ed that a typ­i­cal child with ADHD could be treat­ed with the equiv­a­lent of 5 mg of methylphenidate 2X/day if he/she con­cur­renl­ty received mod­er­ate to high inten­si­ty behav­ior ther­a­py. With­out behav­ior ther­a­py, the same child would require a 20 mg dose 2X/day to attain com­pa­ra­ble ben­e­fits. Thus, the dai­ly reduc­tion in methylphenidate would be 30 mg/day. One rea­son this may be impor­tant is that the appetite sup­pres­sion effects observed in the cur­rent study increased sub­stan­tial­ly with increas­ing dose — the per­cent­age of their lunch that chil­dren ate was 81%, 73%, 59%, and 45% on place­bo, low, medi­um, and high med­ica­tion dos­es respec­tive­ly.

It is also impor­tant to note that for sev­er­al of the out­comes, adding either low or high inten­si­ty behav­ior ther­a­py yield­ed incre­men­tal improve­ments at every dose of med­ica­tion; the effect size for these incre­men­tal gains were fre­quent­ly large. Sim­i­lar­ly, adding med­ica­tion to either vari­ant of behav­ior ther­a­py was asso­ci­at­ed with sig­nif­i­cant incre­men­tal gains at each dose.

Sum­ma­ry and Impli­ca­tions

Results from this study pro­vide a com­pelling demon­stra­tion that adding behav­ior ther­a­py to med­ica­tion treat­ment could enable most chil­dren to be main­tained on sig­nif­i­cant­ly low­er dos­es of med­ica­tion than would oth­er­wise be the case. This could poten­tial­ly reduce the appetite reduc­tion and per­haps growth sup­pres­sion that can be asso­ci­at­ed with pro­longed stim­u­lant treat­ment; it could also be more com­fort­able for many par­ents who have con­cerns about med­ica­tion treat­ment for their child.

While this study high­lights the via­bil­i­ty of this approach, it is worth not­ing that cur­rent prac­tice is gen­er­al­ly not ori­ent­ed in this way. Typ­i­cal­ly, when chil­dren begin med­ica­tion treat­ment for ADHD, the clin­i­cian’s goal is to find a dose that yields the great­est ben­e­fits. The ques­tion of whether sim­i­lar ben­e­fits could be attained through a com­bi­na­tion of less med­ica­tion and behav­ior ther­a­py is not typ­i­cal­ly addressed.

There are lim­i­ta­tions to this study that should be not­ed. First, even the ‘low inten­si­ty’ behav­ior treat­ment pro­vid­ed had mul­ti­ple com­po­nents and could be chal­leng­ing for fam­i­lies to sus­tain over time. Sec­ond, the study occurred in the con­text of an inten­sive sum­mer treat­ment pro­gram, a very dif­fer­ent con­text from where chil­dren spend their dai­ly lives. And, treat­ment results were eval­u­at­ed over only a 9‑week peri­od, with the dif­fer­ent com­bi­na­tion of med­ica­tion dose and behav­ioral treat­ment inten­si­ty last­ing for much short­er times. Thus, the sus­tain­abil­i­ty of the effects, and the gen­er­al­iza­tion to more typ­i­cal envi­ron­ments remains to be demon­strat­ed.

These lim­i­ta­tions not with­stand­ing, a basic point demon­strat­ed by this study is clear and straight for­ward — med­ica­tion dos­es can be decreased when such treat­ment is com­bined with well exe­cut­ed behav­ior ther­a­py. This may be par­tic­u­lar­ly valu­able when chil­dren are unable to tol­er­ate high­er med­ica­tion dos­es and where there are con­cerns relat­ed to appetite reduc­tion and growth sup­pres­sion. By the same token, low­er dos­es of med­ica­tion can reduce the inten­si­ty of behav­ioral treat­ment required to obtain good effects. Such com­ple­men­tary find­ings speak to the val­ue of com­bined treat­ment for many chil­dren with ADHD.

– Dr. David Rabin­er is a child clin­i­cal psy­chol­o­gist and Direc­tor of Under­grad­u­ate Stud­ies in the Depart­ment of Psy­chol­ogy and Neu­ro­science at Duke Uni­ver­sity. He pub­lishes Atten­tion Research Update, an online newslet­ter that helps par­ents, pro­fes­sion­als, and edu­ca­tors keep up with the lat­est research on ADHD, and teach­es the online course How to Nav­i­gate Con­ven­tion­al and Com­ple­men­tary ADHD Treat­ments for Healthy Brain Devel­op­ment.

Pre­vi­ous arti­cles by Dr. Rabin­er: