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A Comparison of Multimodal and Stimulant Medication Treatment

(Note: Attention Research Update receives support from pharmaceutical companies who manufacture stimulant medication to treat ADHD.  Although I do not believe this has influenced the objectivity of the study reviewed below, I want you to be aware of this relationship).

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Although stimulant medication treatment is a helpful intervention for the majority of children with ADHD, this treatment also has important limitations.  In particular, even when treatment is carefully implemented, many children remain impaired in their behavioral and academic functioning and continue to require additional supports.  Academic difficulties – which are especially prominent among children with ADHD –often continue, and although medication treatment is associated with short term gains in academic performance, the ability of such treatment to produce long-term achievement gains is not yet document. As a result, it is generally asserted that academic interventions are important for children with ADHD, regardless of whether they have a co-occurring learning disability.

The academic struggles of children with ADHD are likely to result from multiple factors including inattention, poor organizational and study skills, poor working memory, and perhaps other types of cognitive difficulties.  It thus stands to reason that providing children with specific training/instruction in organizational and study skills, as well as a carefully constructed and individualized educational plan should yield superior academic outcomes than if children are treatment with medication alone. Documenting the benefits of combining a comprehensive academic intervention with medication treatment was one important focus of a study published recently in the Journal of the American Academy of Child and Adolescent Psychiatry (Hechtman, et al., Academic achievement and emotional status of children with ADHD treated with long-term methylphenidate and psychosocial treatment, JAACAP, 43, 812-819). 

Participants were 103 7-9 boys and girls with ADHD who showed a positive response to medication treatment during an initial 5-week trial of stimulant medication.  The sample was restricted to participants who benefited from medication because the key research question was whether a comprehensive multimodal approach is superior to medication alone for children who respond positively to medication.  In addition, because the study treatments were to include 2 full years of medication treatment, it would have been inappropriate to include children who were not positive medication responders.

Children were randomly assigned to one of three conditions: medication treatment only, medication treatment plus multimodal psychosocial treatment, and medication treatment plus “attention control” psychosocial treatment.  The medication treatment provided to all children was immediate release methylphenidate (the study began before the long acting medications more commonly used today were available).  Careful titration was done to identify the optimal dose for each participant and ongoing monitored was conducted so that adjustments could be made as required in order to optimize the ongoing benefits provided by this treatment.


Multimodal Psychosocial Treatment

Children in the multimodal plus methylphenidate group received an extensive array of services that targeted key domains of psychosocial functioning.  These interventions included academic intervention (described below), individual psychotherapy, and social skills training.  Therapy sessions were provided on a weekly basis during year 1 and on a monthly basis during year 2.  The treatment focused on educating children about ADHD and its treatment; children's attitudes towards taking medication, enhancing self-esteem through positive feedback, and developing effective social skills and social problem solving skills.  In addition, children's parents received training in behavior management and educational information about ADHD.  Finally, teachers completed daily report cards so that children could be rewarded at home for meeting behavioral and academic expectations at school. 

The academic intervention was also extensive.  It included 16 weekly 1 hour sessions in which 4-5 children worked with a master’s degree level special education teacher on organizational skills, study skills, organization of written work, and following instructions.  To maximize the training’s relevance, materials included children's schoolwork.  Following the 5 week organizational study skills program, special education teachers implemented worked with children on a weekly basis for 8 months to implement an individualized academic plan.  The emphasis was on helping children with their current academic work while continuing to provide practice and instruction in organizational and study skills.  Remedial tutoring in reading, writing, and math was provided as needed. 

Clearly, this was a comprehensive approach for helping children with ADHD.  In fact, it would be quite difficult to obtain this coordinated array of services in many communities.


Attention Control Psychosocial Treatment

Children assigned to this group worked with college level non specialists on a variety of nonacademic projects.  General assistance with homework was provided, but specific academic difficulties were not addressed, nor were children provided with specific strategies to overcome them.  This condition was included so the researchers could determine whether simply providing additional individual and small group time with an empathetic adult, rather than the comprehensive multimodal intervention described above, would convey benefits above and beyond those provided by medication.


Measures

Although a wide variety of outcomes were evaluated in this study, the results summarized below are limited to academic outcomes.  All participants were administered a standardized test of academic achievement – i.e., the Stanford Achievement Test – to assess their proficiency in math, reading, comprehension and spelling.  This assessment was conducted before treatment began (i.e., baseline), and then again 12 and 24 months later. This enabled the researchers to measure change in achievement over time, and to learn whether children receiving the multimodal psychosocial treatment made greater academic progress than children in the other groups. 

In addition to this standardized achievement measure, parents rated children's homework behaviors using the Homework Problem Checklist.  This scale was used to assess problems that parents observed their child to have with accurately completing homework assignments.


Results

The authors predicted that children who received academic intervention as part of multimodal treatment would obtain higher achievement ratings at both 12 and 24 months compared to children in the other 2 groups. 

Quite surprisingly, there was no evidence to support this prediction.  As expected, children in all 3 groups showed achievement gains over time.  These gains reflect the learning that occurs during the course of each school year.  Contrary to expectations, however, the achievement gains made by children receiving the academic intervention were no greater than gains made by children who received medication alone, or medication plus the non-specific adult attention.  In fact, there was essentially no indication that the extensive multimodal intervention was associated with better long-term academic performance at either the 12 or 24-month assessment.

Similar results were obtained for parents’ report of homework difficulties.  As with the achievement results, children in all 3 groups were reported to experience fewer homework problems over time.  However, the reduction in homework problems was essentially equivalent for children in the 3 groups.


Summary and Implications

The authors of this study expected that the academic intervention provided to children as part of multimodal treatment would enhance the effect of medication treatment and lead to superior academic outcomes.  Contrary to these expectations, however, no such incremental benefits were found.  The authors’ state, “Because remediation and psychotherapy were part of a comprehensive psychosocial intervention, the lack of efficacy on academic… functions reflects the failure of a broad-based, intensive effort to supplement the impact of long-term stimulant treatment.”  Although not discussed in this particular review, similar negative findings were also obtained for emotional functioning, peer relations, and behavioral functioning. 

The clinical implication they draw from these results is that children with ADHD who respond positively to medication treatment and who are not comorbid for learning or conduct disorders will not routinely benefit from comprehensive multimodal interventions.   Thus, whether these additional interventions should be routinely provided is called into question.  This is a controversial implication, as it appears to contradict a commonly held view that medication treatment alone is generally inadequate for children with ADHD, and that a comprehensive multimodal approach is routinely preferable.  I have even seen these results interpreted as indicating that there is generally no value in providing ADHD treatments beyond medication alone. 

There are a several important reasons, however, why such an interpretation is problematic.

First, some children with ADHD do not benefit from medication or experience adverse effects that prevent them from taking it.  In this study, participants were restricted to positive medication responders and the results thus have no implications for children who are not.

Second, the medication treatment provided in this study is likely to have been more carefully conducted than in routine community care.  As a result, the benefits participants received may have been greater than is typical for children treated in community settings.  If this is the case, than community-treated children may frequently have greater need for additional supports.  (For a free special report on procedures for maximizing the benefits of medication treatment, please visit www.helpforadd.com/medreport.htm ).

Third, as the authors note, their findings do not apply to children with ADHD who also have specific learning disabilities, which is approximately 15-20% of the ADHD population. 

Fourth, as the authors also note, their findings are limited to 7 to 9 year old children, and their results cannot be generalized to preschoolers or adolescents.  It is possible that a different pattern of results would be found for these age groups.  In particular, given the increased organizational and study skill demands that children experience upon entering middle school, the academic intervention implemented in this study may have provided more discernible benefits to older students.  This would be an important question to pursue in subsequent research.

Fifth, the overall absence of group difference reported may have obscured differences that occurred in particular subgroups.  For example, among children with ADHD, as among all children, there is enormous variability in academic performance.  It would have been instructive to examine the impact of the multimodal treatment on those children who demonstrated the greatest academic difficulty at the beginning of treatment.  Perhaps for those with the greatest need, the academic intervention provided benefits above and beyond medication, even though such benefits were not evident among children who had with fewer academic struggles to begin with.  Unfortunately, because there were less than 35 children in each treatment group, examining outcomes for particular subgroups would be difficult.

Sixth, it should be noted that in the MTA Study, which is the largest treatment study of ADHD ever conducted, and which also compared outcomes for children receiving medication treatment alone vs. children receiving medication treatment plus intensive behavior therapy, modest benefits were observed for children receiving combined treatment.  The superiority of combined treatment was not evident in any individual outcome, but became evident when different outcomes were combined into a more global measure of overall functioning.  In this study, the authors examined each outcome individually.  Perhaps combining outcomes across different domains to produce a composite functioning index would have shown the benefits of the multimodal approach. 

Seventh, although the multi-modal treatment employed in this study, one cannot conclude that other interventions besides those used here may not have added to the benefits provided by medication.

Two final points are important to emphasize.  First, because there was not a no-treatment control group, or a non-ADHD comparison group, it is difficult to determine how much participants benefited from the treatments provided.  The fact the 3 groups did equally well does not mean that treatment was effective in normalizing their academic functioning.  In fact, given what has been learned from other studies, it is likely that many children continued to experience important academic difficulties despite treatment.  Thus, these results cannot be interpreted as indicating that for children who respond positively to medication, there is no need to continue to work towards developing effective academic interventions.

Finally, because multimodal interventions were given to children who were already known to be positive medication responders, one cannot conclude that the additional interventions provided were not effective, as we do not know what their impact would have been on non-medicated children.  For example, it is possible that if children received the multimodal treatment in the absence of medication, they may have done as well as children treated with meds.  This is not a fault of the study, as it was not designed to answer this question.  However, it is easy to misinterpret the results of this study as indicating that the psychosocial interventions provided were not effective, rather than the more appropriate conclusion, which is they apparently did not provide incremental benefits to children who were positive medication responders.

In conclusion, results from this study indicate that in children who benefit from medication treatment, and who receive carefully monitored medication treatment on an extended basis, even comprehensive multimodal intervention may not be superior to medication alone in regards to long-term academic achievement.  Thus, for these children, additional supports may not be needed on a routine basis.  However, for children who continue to struggle despite medication treatment, or who fail to respond positively to medication, interventions such as those provided here may be critically important and necessary.