Do Children with ADHD Benefit From Psychosocial Intervention?

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Do Children with ADHD Benefit From Psychosocial Intervention? 

 

Sam Goldstein, Ph.D.
This is a SamGoldstein.com Monthly Article - August, 2004
Copyright © 2004 Dr. Sam Goldstein - All Rights Reserved

How effective is methylphenidate and the other medications used to treat ADHD in childhood? What percentage of relief from ADHD symptoms and consequent impairments on the playground, in school, at home or in other arenas is accounted for by the medication? In fact, does significant symptom presentation and impairment remain in good medication responders? Do children with ADHD who are good medication responders require or for that matter benefit from typical psychosocial interventions, including counseling, academic support and social skills development. Finally, do children receiving combined treatments demonstrate greater functioning over time and possibly require lower doses of medication? These questions have been repeatedly addressed in part through scientific inquiry but mostly in the clinical and popular media. It has become "politically correct" to recommend psychosocial treatment and to state unequivocally that medication treatment for ADHD should be considered as part of a comprehensive treatment program. This theme is portrayed in many of the dozens of advertisements promoting medications for ADHD in clinical and popular media. In past articles, I too have written of the importance of psychosocial interventions for youth with ADHD. However, I focus not on the potential symptom relieving benefits of these interventions but as with my recent article advocating psychotherapy for youth with ADHD, as supportive interventions for children who may experience comorbid problems or specific skill weaknesses. In this month's article, I will review a series of recently published studies addressing the use of stimulant medication and multi-modal psychosocial treatment in ADHD.

Over the past thirty years, a valid and reasonable series of studies have been completed demonstrating that medication treatment for ADHD by far leads to the majority of symptom relief and impairment reduction in a combined treatment program. However, it is still debated whether multi-modal psychosocial treatments for example should be tried first in children with mild symptom presentation and impairment, should be included as part of every child's treatment plan, should be added only if children are refractory or inconsistent responders to medication or whether the inclusion of these interventions may lead to better long-term outcome. Answering these questions requires complex, frequently longitudinal studies. Many of these questions continue to remain unanswered. A recent five year multi-site ADHD study completed by the National Institute of Mental Health attempted to comprehensively address these questions. Multiple research articles have been generated from these data. The majority suggest that medication treatment alone by far accounts for the majority of symptom relief and impairment reduction. However, some articles in this series have suggested that adding psychosocial treatments may provide added benefit.

A multi-year longitudinal study also addressing these issues completed between 1990 and 1995 was just presented in a series of research articles. The senior researchers of this study are among the most respected in the field of ADHD research. This longitudinal study was undertaken in a dual site program in New York and Montreal with 103 children with ADHD between the ages of seven and nine years. In an effort to control for confounding or unwanted variables that could affect outcome, these children were all free of conduct and learning disorders. Additionally, these children had also responded well to methylphenidate treatment. It is important to note that this is not a common population for children with ADHD for whom comorbid problems are usually the rule rather than the exception. However, designing a study this way allows for a direct examination of the relationship between ADHD symptoms, impairment and treatment.

The children were randomized for two years into three different treatment groups. The first group received methylphenidate only. For those unaware, methylphenidate is also marketed a Ritalin, Methylin or Concerta. The second group received methylphenidate combined with multi-modal psychosocial treatment. This treatment included parent training and counseling, academic assistance, psychotherapy and social skills training. The third group of children received methylphenidate plus attention control treatment. This treatment excluded specific aspects of the psychosocial interventions but provided parents with general support. The children were switched to single, blind placebo after twelve months. Methylphenidate was re-instituted when clinically indicated. Assessments included ratings by parents, teachers, children and psychiatrists, direct observations in multiple settings in school and measures of academic performance. Nearly 80% of families completed the two year study. The psychosocial component was comprehensive. In the first year, parents received one and a half hours of parenting support weekly as well as one hour of family therapy. Children received one hour per week of individual psychotherapy, social skills training as well as academic support. In the second year, these interventions were maintained but reduced to one hour per month.

It is also important to understand that research findings are frequently influenced by definition of terms, the ability to control unwanted variables that might influence outcome but even more importantly, outcome measures used to prove or disprove hypotheses. In this study, outcome measures were specifically related to kinds of behaviors problematic for youth with ADHD. The authors hypothesized that the combination of treatments would be superior to methylphenidate alone relative to parent knowledge, attitude, parenting practices, academic behavior, achievement and social interaction. They hypothesized that the combination of treatments would lead to greater symptom reduction and less impairment. The authors predicted that there would be a "significant advantage to adding multimodal psychosocial intervention to methylphenidate treatment and after one year stimulant treatment could be withdrawn more successfully in the combined treatment group than in the methylphenidate group alone." Readers interested in reviewing the series of studies cited in this article will find them in the Journal of the American Academy of Child and Adolescent Psychiatry, July issue, Volume 43, pages 782 to 838. I believe this study will have a significant impact in the ongoing controversy as to whether youth with ADHD who are positive methylphenidate responders do in fact require or derive added benefit from psychosocial treatments. Let me briefly review these findings.

  • In stimulant responsive children with ADHD, these articles demonstrate that there was "no support for adding ambitious, long-term, psychosocial intervention" to improve ADHD.
  • Significant benefits from methylphenidate were stable over the two year period.
  • There was no support for added benefit from academic assistance in this group of children with ADHD without learning and conduct disorders.
  • There was no support that psychotherapy led to improved behavioral outcome for this group of children.
  • There was no support that these education and psychosocial interventions enhanced academic achievement nor emotional adjustment.
  • There was no support for suggesting that clinic based social skills training improved social behavior beyond the improvements noted from methylphenidate alone.
  • There was no support that parent training improved self-rated parent behaviors.
  • Parents receiving parenting support reported a better understanding as well as general knowledge about their children's behavior. However, this did not translate into enhancement of parenting practices as rated by parents and children.
  • The benefits of stimulant treatment observed immediately were sustained with extended treatment.

We should choose our words and opinions carefully in this treatment debate. I have long advocated that "pills will not substitute for skills." Keep in mind, however, that the basis of ADHD is not that these children are skill deficient, or that they don't know what to do, but that they do not consistently, predictably and independently do what they know. A large body of research demonstrates that children with ADHD understand and are capable of comprehending the world around them at a level consistent with other children. They do not do so because they are impulsive, inattentive, hyperactive and generally inefficient in regulating their cognitive skills and abilities. When the discussion is specifically reserved to symptom relief and impairment reduction for ADHD, this series of articles adds to an impressive body of scientific literature demonstrating that medication treatment, in this case methylphenidate, may be all that is needed for good responders. However, not all children with ADHD are robust responders to medication. Further, when the discussion turns to children's thoughts, feelings, attitudes, beliefs and the host of variables that encompass what Dr. Robert Brooks and I refer to as their "mindsets", when we recognize that the majority of children struggling with ADHD experience multiple comorbid problems, some of which may respond to medication but most of which do not respond particularly robustly, it becomes apparent that there is a need to combine a variety of interventions to help these children. In fact, here too there is a large body of research demonstrating the need for academic support for children with ADHD combined with learning disability; for behavioral support, for children with ADHD combined with disruptive behavior disorders; for psychotherapeutic support, for children with ADHD struggling to understand and accept their condition or experiencing internalizing problems related to depression or anxiety. It is neither bad nor politically incorrect accepting the premise that medication treatment for ADHD is and should be considered a first line, primary intervention for children whose symptoms and impairment cause significant disruption in their every day lives.