Is Behavior Therapy as Effective as Pharmacologic Treatment?
Although research studies had extensively explored the short-term efficacy and limitations of psychosocial and pharmacologic treatment of ADHD by the early 1990s, these studies did not produce comprehensive data on the differential treatment effects and comparative long-term efficacy of these approaches. To address this need, researchers launched 2 landmark multisite clinical trials. In 1992, the National Institute of Mental Health (NIMH) launched the Multimodal Treatment Study of Children with Attention-Deficit/Hyperactivity Disorder (MTA), in which 579 children with a primary Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnosis of ADHD-combined type were randomly assigned to 1 of 4 experimental arms: expert titrated stimulant medication vs behavioral treatment vs combination of medication and behavioral treatment vs community-based treatment. Behavioral treatment consisted of both clinical behavior therapy (parent training and school consultation) and direct contingency management. Approximately one third of the sample had a comorbid anxiety disorder.
The primary finding of this study was that behavioral treatment was not as effective at reducing ADHD symptoms as medication. Secondary findings included (1) patients in all treatment conditions experienced significant improvement over time, including those who did not receive medication, and (2) combined treatment (medication and behavior therapy) outcomes were achieved with significantly lower medication doses than used in medication management. Finally, combined treatment (medication and behavior therapy) was particularly effective for treating disruptive behaviors and internalizing symptoms in ADHD children with comorbid anxiety.
In 2004, in an attempt to improve upon the MTA study, researchers conducted a second multisite study comparing multimodal psychosocial treatment with stimulant medication. The sample consisted of 103 children who met the DSM-IV diagnostic and severity criteria for ADHD and had previously demonstrated a response to stimulants. This second study differed from MTA in that an attention control condition was included to allow researchers to explore the incremental value of psychosocial treatment. Unfortunately, psychosocial treatment for this study included a number of interventions of questionable efficacy with this population, such as clinic-based social skills groups, organizational skills instruction, and individual therapy. Moreover, parent training appeared to have been less than optimal. Although participants in the parenting program demonstrated better knowledge of parenting practices than those who did not participate, this knowledge did not actually enhance their parenting practices, demonstrating the prevalent disconnect between knowledge and implementation of the knowledge. Finally, school consultation and direct contingency management programs were notably absent.
Results from this study suggested that psychosocial treatments did not significantly improve functioning of stimulant-responsive children on any outcome measures. In their conclusion, the researchers noted that "in stimulant responsive children with ADHD there is no support for adding ambitious long-term psychosocial interventions to improve ADHD and oppositional defiant symptoms."
Reactions to the results of both studies have been vigorous. Researchers have debated the design of the studies[22,23]; clinicians have questioned the cost-effectiveness of psychosocial treatments compared with stimulant medication for the general population of ADHD children. In a recent editorial, Diller and Goldstein even expressed concern that "These 2 studies appear(ed) to drive the final nail into the psychosocial treatment coffin."
Although interesting, many of these discussions seem misdirected. It is undeniable that stimulant medication is highly effective for treating ADHD symptoms. With appropriate medication management, most children may not need multimodal treatment. However, several subpopulations will require treatment with behavior therapy.
Medscape Psychiatry. 2006;11(2) © 2006 Medscape
Cite this: Nonpharmacologic Approaches to Treating ADHD - Medscape - Aug 01, 2006.