Science, Ethics and the Psychosocial Treatment of ADHD

The following Editorial authored by myself and pediatrician, Lawrence Diller, M.D., was just published in the Journal of Attention Disorders, May, 2006 (Volume 9, pages 571-574) issue. My original plan for this month’s E Newsletter was to write a simplified version of this Editorial. However, upon further review I have decided that the Editorial as written for the professional journal can be read and understood by lay persons as well as professionals. For this reason, the Editorial appears below as published in the Journal of Attention Disorders, a scientific journal for which I serve as Editor-in-Chief.

Science, Ethics and the Psychosocial Treatment of ADHD

Lawrence Diller, M.D.
Sam Goldstein, Ph.D.
May, 2006
Copyright © 2006

No scientific undertakings or hypotheses are completely divorced from the social values of their time and place.
--Russell A. Barkley, Ph.D.

Psychosocial treatments such as behavior modification figure prominently in the guidelines for the treatment of ADHD from both the American Academy of Pediatrics (AAP, 2000; AAP, 2001) and the American Academy of Child and Adolescent Psychiatry (Greenhill, 2002). But given the results of recent studies, are these recommendations simply political concessions to nurture advocates and the biopsychosocial model? Are parents unfairly biased when they rate behavior therapy as more acceptable than medication for the treatment of their child's ADHD (Krain, Kendall and Power, 2005)? Is it finally time to concede that psychosocial interventions add "nothing" to stimulant medication treatment and need not be pursued for uncomplicated ADHD as some prominent recent reviews have suggested (Rappley, 2005)? The answers to these and related questions, while important for individual families, also have great implications for social policy (e.g., funding of schools, parenting programs or treatment modalities). It is assumed that the answers to these questions are known and in a fair and reasoned way guiding such policy. Indeed, for the most part they are not known nor guiding policy.

More than one hundred studies demonstrate that parent and teacher training programs improve child compliance, reduce disruptive behaviors and improve parent/teacher-child interactions (Pelham, Wheeler & Chronis, 1998: Pelham, Massetti, Wilson Kipp, Myers, Stadley, Billheiner & Waschbusch, 2005; Maughan, Christiansen, Jenson, Olympia and Clark, 2005). Though a number of short-term studies have scientifically demonstrated the effectiveness of psychosocial interventions for ADHD (Evans, Langberg, Raggi, Allen & Buvinger, 2005; Semrud-Clikeman, Nielsen, Clinton et al., 1999; Tutty, Gephart & Wurzbacher, 2003) the case for medication's exclusive status in ADHD treatment derives from two major studies. The first is the National Institute of Mental Health ADHD Treatment (MTA) ongoing study of 600 children (Special Section, JAACAP, 2001). Three years after the initial MTA results were published Klein, et al. published a series of articles reviewing their study of 103 children over a three-year period (Klein, Abikoff, Hechtman et al., 2004; Klein, Weiss, Fleiss, et al., 2004). A multi-site population of highly screened, well-diagnosed, impaired children with ADHD characterized the subjects of both studies. Most importantly, unlike previous long-term research on ADHD, children in both studies were randomized into medication only, combined treatment and community treatment groups.

The initial headlines from the MTA study emphasized that the combined medication and psychosocial treatment group did no better than the medication only group. However, further analysis of the data indicated that this was true only for the minority of children with uncomplicated ADHD (Conners, Epstein, March, et al. 2001). The majority of participants diagnosed with ADHD also had co morbid ODD and/or anxiety. Adding the psychosocial component for these youth to medication treatment statistically improved outcomes compared to the medication only group (Conners, Epstein, March, et al., 2001). Data collected after two years tended to further diminish the superiority of the medicated groups (alone or combination) over the psychosocial only and community based service groups for all the children in the study (MTA Cooperative Group, 2004).

The subsequent study completed in New York City and Montreal was firmer in its conclusions about the lack of increased benefits in adding psychosocial treatment to the effects of medication alone. Over a variety of parameters (e.g., academic achievement, socialization, emotional status, parent practices) the conclusions were the same. The authors were quite clear about the lack of benefits from psychosocial interventions for ADHD when medication was employed.

These two studies appear to drive the final nail into the psychosocial treatment coffin. Despite APA and AACAP guidelines suggesting equality between treatment choices, these studies have been used to promote a medication first approach to ADHD. An MTA research paper was mailed to pediatricians and child psychiatrists in the United States by one of the manufacturers of a medication used to treat ADHD. But whether or not, on medical or moral grounds, medication should be the primary approach in a community diagnosed population with ADHD remains unclear.

Category Versus Dimension

As a defined condition in the DSM-IV-TR, ADHD represents a category while the symptoms of ADHD are clearly dimensional in nature. Who exactly are the children with ADHD comprising the subject pool in published research, which ultimately guides clinical practice? Are they the more severely symptomatic and impaired? It is likely that a more rigid and stringent application of DSM criteria is applied to children participating in peer reviewed and published research studies (Handler and DuPaul, 2005). Children in these studies may also be more symptomatic and impaired than children in the community. Further, data on who receives medication in the community is inconsistent and confusing. Epidemiologic studies suggest overall these medications are not necessarily over-prescribed (Jensen, Kettle, et al., 1999) but their use is increasing (CDC, 2005; Medco, 2005). It seems in real world pediatrics, ADHD is often missed (Bussing, Zima, Perwien, et al. 1998). Stimulants are usually prescribed for the most impaired (Barbaresi, Katusic, Colliganet, et al., 2002), but as much as half the time stimulants may be prescribed for children who don't meet full DSM criteria for the ADHD diagnosis (Angold, Erkanli, Egger, et al., 2000).

Further, in severe cases of ADHD, the effects of psychosocial interventions may not be as obvious. But the same may not be true for children with borderline or mild ADHD. This group of less impaired children, given the bell-shaped distribution and dimensional nature of the symptoms of ADHD, surely in the community represent the majority of the cases a community-based clinician might treat. Various studies suggest that behavioral approaches seem effective with ADHD (Chako, Pelham, Gnagy, Griener, et al, 2005). Studies have also demonstrated that the intensity of psychosocial interventions becomes dose equivalent in reducing the amount of stimulant medication necessary to control symptoms (Chako, Pelham, Gnagny, et al, 2005). Medication works but when given as the first treatment may obscure the benefits of psychosocial interventions. Even in the MTA and Klein studies which found no statistically significant improvements when psychosocial treatments were added, the authors reported that parents from the combined treatment approach groups developed, not only a better understanding of their children, but a better feeling for them also.

The behavior of these children might not have been that different before and after behavioral training but parents' attitudes could have fundamentally changed. These parents may have a better sense of the problem and perception of increased control over their children. DSM based research would only focus on the symptoms of the child and equate symptom relief with improvement (Sawyer, Rey, Arney, et al, 2004). Impairment, an even more elusive quality, however, might indeed decrease even without any overall symptom change, in that impairment is a function of the children's behavior within the context of the environment's expectations and responses. Parental attitudes and behavior might well immediately affect measures of impairment while measures of children's behavior might remain the same or improve slowly over time. Indeed, the notion of problem is more closely tied to impairment than symptoms, a point often lost or obscured in mainstream DSM based research (Gordon, Antshel, Faraone, et al., 2006).

Science, Ethics and ADHD

Science is about proof, replication and utility. Yet the scientific discussion on ADHD has rarely focused on moral and ethical issues as we decide the best course of action for children with developmental disabilities. We do not disagree with the science that has demonstrated stimulant medications are efficacious in assisting and addressing the needs of children with ADHD, their families and schools. We are, however, uneasy about the use of medication as the first and only treatment for all cases of ADHD, particularly in the absence of convincing longitudinal data suggesting symptom relief alone changes future lives for the better. Children's positive response to stimulant medication is not equivalent to improving their environment and future by assisting their parents, schools and general communities. Though medication treatment is cost effective and may be all that is needed in the short term to reduce symptoms and impairment for many children with ADHD (Jensen, Garcia, Glied, Crowe, Foster, et al, 2005), we recognize the logical fallacy of making medication, even when effective, the equivalent of psychosocial interventions.

The universal enhancing effects of stimulant medications is critical for moderate and severely impaired children with ADHD. But substituting the ubiquitous effects of stimulants (out of cost, speed or convenience) for psychosocial interventions for borderline to mildly impaired children with ADHD is morally dubious. In addition there are side effects to these medications along with unanswered questions about long-term outcomes. Though some children will do fine with stimulant medication alone, shouldn't their parents at least be given better operating instructions for their children?

Where Do We Go From Here?

Despite seventy years of stimulant use in psychiatry we still do not know for certain the best long-term treatments for ADHD. Pills are no substitute for skills; symptom relief is not the equivalent of changing long-term outcome for the better. Children with ADHD do in fact learn to self-regulate albeit not as quickly as others. They need more practice. Practice facilitates proficiency. No one would argue this is not the case. Much better for them if they can learn to self-regulate within the confines of their homes under the loving guidance and caring supervision of their parents rather than learning outside of the home in the communities we have created; communities that hold so many potential adversities for them (for review see Goldstein and Teeter, 2002).

Though we are reassured by a number of brief meta-analytic studies of the efficacy and safety of long-term stimulant use (Connor, Glatt, Lopez, et al., 2002; Faraone, Spencer, Aleardi, et al., 2004), we may never know for sure whether medication use is safe and effective through multiple decades of life. Do psychosocial interventions add anything to medication? This too we may never know for sure when ADHD is equated with a broad base of life and family issues. Without a definitive answer, we are not prepared to abandon parenting and educational strategies for medication alone. We acknowledge that even the strongest advocates for medication use for children with ADHD would not argue this. Yet when studies conclude that psychosocial interventions add little or nothing to the treatment of ADHD, we worry about the implications of such a message on public policy and its effects on the professional and lay communities.

Finally, human beings should not be defined by their handicapping conditions, but rather their conditions should be understood within the broader context of the forces that shape their lives. This leads us to question the means by which we apply evidence based or scientifically validated treatments within the broader community. Because psychosocial treatments, particularly psychotherapy, are directed not just at symptom relief or changing behavior but changing thinking as well, it is worth addressing the case for psychosocial treatments for conditions such as ADHD.

The debate over psychosocial treatments versus medication has profound implications for the way our society decides to view and treat children with emotional, behavior and performance problems. The controversy over treatments for ADHD is yet another reflection of the nature/nurture debate. With ADHD, researchers and leaders in the field of child psychiatry, psychology and pediatrics continue to fight a rear guard battle against the legacy of a half a century of blaming mothers associated with the Freudian hegemony in our society. While remnants of the Freudian model remain viable, it is time to declare the battle over. However, insisting that the basis for behavior in children and adults is only biological and driven by heredity is simplistic, reductionistic and in fact does not fit the emerging research concerning gene/environment interaction (Deater-Deckard, Ivy & Smith, 2004). Psychosocial treatments for ADHD have consequently suffered despite their promise (Strayhorn, 2002a & b), perhaps in part in that we have failed as a field to develop a comprehensive program that includes stock dividends or equity. But it also seems at this point overkill - bad for children - bad for society - to imply in one way or another over and over again that parenting doesn't matter. Advocating for psychosocial treatments for ADHD is not simply a matter of political correctness. It is the recognition of a moral and clinical reality that for most children with ADHD, a combination of psychosocial and medical interventions will best serve their present and future needs.

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