|Improvement Following ADHD Treatment Sustained
in Most Children
But Linked Problems Persist Into Adolescence — Major
Most children treated in a variety of ways for attention deficit
hyperactivity disorder (ADHD) (http://www.nimh.nih.gov/healthinformation/adhdmenu.cfm)
showed sustained improvement after three years in a major follow-up
study funded by the National Institutes of Health’s (NIH) National
Institute of Mental Health (NIMH). Yet increased risk for behavioral
problems, including delinquency and substance use, remained higher
The study followed-up children who had participated in the Multimodal
Treatment Study of Children with Attention Deficit Hyperactivity
Initial advantages of medication management alone or in combination
with behavioral treatment over purely behavioral or routine community
care waned in the years after 14 months of controlled treatment
ended. However, Peter Jensen, M.D., Columbia University, and colleagues
emphasized that “it would be incorrect to conclude from these results
that treatment makes no difference or is not worth pursuing.”
Their report is among four on the outcome of the MTA study published
in the August, 2007 Journal of the American Academy of Child
and Adolescent Psychiatry (JAACAP).
“We were struck by the remarkable improvement in symptoms and
functioning across all treatment groups,” explained Jensen.
After three years, 45-71 percent of the youth in the original
treatment groups were taking medication. However, continuing medication
treatment was no longer associated with better outcomes by the
“Our results suggest that medication can make a long-term difference
for some children if it’s continued with optimal intensity, and
not started or added too late in a child’s clinical course,” added
For the followup study, a multi-site research team evaluated,
at ages 10-13, 485 children from the original MTA study (http://www.nimh.nih.gov/childhp/mtaqa.cfm),
the first major randomized trial comparing different treatments
for ADHD, published in l999. That study found that intensive medication
management alone or in combination with behavioral therapy produced
better outcomes than just behavioral therapy or usual community
Ratings from families and teachers favored the combination treatment,
which allowed for somewhat lower medication doses. Also, the careful
management of medication by MTA physicians produced better outcomes
than medication provided through usual community care sources.
After the 14 months of assigned treatments ended, families were
free to choose from treatments available in their communities.
To understand why the initial advantage of medication wore off,
the researchers examined medication use patterns that emerged after
formal treatment in the study ended. They found that children who
had been assigned to intensive behavioral treatment were more likely
to begin taking medication, while those who had been taking medication
were more likely to stop. For example, among children originally
in the behavioral treatment group, the incidence of high medication
use increased from 14 to 45 percent.
In a secondary analysis of the data that searched for possible
explanations for the findings, in the same issue of the JAACAP,
researchers led by James Swanson, Ph.D., University of California
at Irvine, reported finding substantial individual variability
in responses to medication. They identified three groups of children
with different patterns of response. One group, about a third of
the children, showed a gradual, moderate improvement; a second
group, about half of the children, showed larger initial improvement,
which was sustained through the third year; a third group, about
14 percent of the children, responded well initially, but then
deteriorated as symptoms returned during the second and third years.
Swanson and colleagues suggested “trial withdrawals” for some children
to determine if they still need to take medications.
Another report by Swanson and colleagues in the same issue of
the JAACAP confirmed an earlier finding from the MTA study
that taking medication slowed growth. A group of 65 children with
ADHD who had never taken medication grew somewhat larger — about
three-fourths of an inch and 6 pounds more, on average — than
a group of 88 peers who stayed on medication over the three years.
Growth rates normalized for the children on medication by the third
year, but they had not made up for the earlier slowing in growth.
In a fourth article, Brooke Molina, Ph.D., University of Pittsburgh,
and colleagues reported that, despite treatment, the children with
ADHD showed significantly higher-than-normal rates of delinquency
(27.1 percent vs. 7.4 percent) and substance use (17.4 percent
vs. 7.8 percent) after three years. Earlier evidence of lower substance
use rates among children who had received intensive behavioral
therapy had lessened by the third year. “These findings underscore
the point that ADHD treatment for one year does not prevent serious
problems from emerging later,” noted Molina.
The follow-up of the MTA sample will continue as the participating
children go through adolescence and enter adulthood.
The following researchers participated in the studies:
Three-year Follow-up of the NIMH MTA Study. Peter S. Jensen, L.
Eugene Arnold, James M. Swanson, Benedetto Vitiello, Howard B.
Abikoff, Laurence L. Greenhill, Lily Hechtman, Stephen P. Hinshaw,
William E. Pelham, Karen C. Wells, C. Keith Conners, Glen R. Elliott,
Jeffery N. Epstein, Betsy Hoza, John S. March, Brooke S.G. Molina,
Jeffrey H. Newcorn, Joanne B. Severe, Timothy Wigal, Robert D.
Gibbons, Kwan Hur.
Secondary Evaluations of MTA 36-Month Outcomes: Propensity Score
and Growth Mixture Model Analyses. James M. Swanson, Stephen P.
Hinshaw, L. Eugene Arnold, Robert D. Gibbons, Sue Marcus, Kwan
Hur, Peter S. Jensen, Benedetto Vitiello, Howard B. Abikoff, Laurence
L. Greenhill, Lily Hechtman, William E. Pelham, Karen C. Wells,
C. Keith Conners, John S. March, Glen R. Elliott, Jeffery N. Epstein,
Kimberly Hoagwood, Betsy Hoza, Brooke S.G. Molina, Jeffrey H. Newcorn,
Joanne B. Severe, Timothy Wigal, and the MTA Cooperative Group.
Effects of Stimulant Medication on Growth Rates Across 3 Years
in the MTA Follow-up. James M. Swanson, Glen R. Elliott, Laurence
L. Greenhill, Timothy Wigal, L. Eugene Arnold, Benedetto Vitiello,
Lily Hechtman, Jeffery Epstein, William E. Pelham, Howard B. Abikoff,
Jeffrey H. Newcorn, Brooke S.G. Molina, Stephen P. Hinshaw, Karen
C.Wells, Betsy Hoza, Peter S. Jensen, Robert D. Gibbons, Kwan Hur,
Annamarie Stehli, Mark Davies, John S. March, C. Keith Conners,
Mark Caron, Nora D. Volkow, for the MTA Collaborative Group.
Delinquent Behavior and Emerging Substance Use in the MTA at 36-Months:
Prevalence, Course, and Treatment Effects. Brooke S. G. Molina,
Kate Flory, Stephen P. Hinshaw, Andrew R. Greiner, L. Eugene Arnold,
James M. Swanson, Lily Hechtman, Peter S. Jensen, Benedetto Vitiello,
Betsy Hoza, William E. Pelham, Glen R. Elliott, Karen C. Wells,
Howard B. Abikoff, Robert D. Gibbons, Sue Marcus, C. Keith Conners,
Jeffery N. Epstein, Laurence L. Greenhill, John S. March, Jeffrey
H. Newcorn, Joanne B. Severe, Timothy Wigal, and the MTA Cooperative
Group. The Office of Special Education Programs of the U.S. Department
of Education, the Office of Juvenile Justice and Delinquency Prevention
of the Justice Department, and the National Institute on Drug Abuse
(NIDA) also participated in funding this study.
The National Institute of Mental Health (NIMH) mission is to reduce
the burden of mental and behavioral disorders through research
on mind, brain, and behavior. More information is available at
the NIMH website, http://www.nimh.nih.gov.
The National Institutes of Health (NIH) — The Nation's
Medical Research Agency — includes 27 Institutes and
Centers and is a component of the U.S. Department of Health and
Human Services. It is the primary federal agency for conducting
and supporting basic, clinical and translational medical research,
and it investigates the causes, treatments, and cures for both
common and rare diseases. For more information about NIH and
its programs, visit www.nih.gov.