Although medication treatment for ADHD has important limitations, there have been numerous studies in which it has been shown to be an effective intervention for many children with ADHD. Recent results from the MTA Study, the largest treatment of ADHD ever conducted (See for details) indicate that it is especially effective in reducing core ADHD symptoms, and that the combination of careful medication treatment and intensive behavior therapy is particularly helpful for many children. Thus, although there remains a pressing need to develop and research alternative treatments for ADHD, and promising results of such treatments have been reported in prior issues of this newsletter, the research support for medication treatment is substantial.

An important and concerning limitation in the existing treatment literature, however, is that although numerous studies have demonstrated the short-term benefits of carefully conducted medication treatment, evidence that such treatment yields long-term gains for children is relatively sparse. Given that medication treatment is so clearly beneficial for many children in the short-run, why has documenting long-term benefits been more difficult?

One obvious explanation for this is that there have been remarkably few studies in which children receiving medication treatment have been followed for more than a year. In fact, to my knowledge, there is not a single study in which outcomes for children who have received carefully managed medication treatment that lasted beyond 14 months have been examined.

In the closest approximation of such a study to date - the MTA Study - children who received well-conducted medication treatment over a 14-month period were examined 10 months after treatment ended, during which time they may or may not have continued treatment. Results indicated children who had received medication treatment through the study continued to demonstrate lower levels of core ADHD symptoms than children who had not received this treatment. However, the magnitude of the benefits had clearly diminished over time, and this seemed to be associated with whether or not medication treatment had continued. (See for details).

Although it is certainly possible that the effectiveness of even the most rigorously monitored medication treatment may decrease over time, another possibility for why medication treatment has not yet been clearly shown to yield long-term benefits is that it is often discontinued prematurely. It is now widely accepted that ADHD is a chronic condition for many children, and that it is often associated with difficulties that persist into adolescence and adulthood. Given the chronicity of ADHD, there is little reason to expect that any treatment, no matter how effective it may be in the short-term, will yield important long-term benefits if it is discontinued after a relatively short time. This is especially true of medication treatment for ADHD, which although effective in managing symptoms fro many children, does not cure the disorder.

As reported in a recently published study (Bussing, et al. 2005. Use and persistence of pharmacotherapy for elementary school students with Attention Deficit/Hyperactivity Disorder. Journal of Child and Adolescent Psychopharmacology, 15, 78-85), however, even when medication treatment is provided to children with ADHD it may often be discontinued after a relatively short duration. Participants in this study were 220 children identified as being at high risk for having ADHD based on an initial telephone screening involving over 1600 families whose children attended public school in a southeastern city. Girls comprised over 50% of the sample, 31% were African American, and the average age was just over 8 years. Of these 220 children, 159 were subsequently determined to meet full diagnostic criteria for ADHD based on a structured psychiatric interview.

Concurrent with the diagnostic assessment, parents were asked whether their child was receiving either medication treatment for ADHD, or any special school-based services. This same information was collected 12 months later.

RESULTS

Twelve months later, only 64% of children who had been receiving medication treatment remained on medication. Thus, only 27% of children with ADHD, i.e., 42% X 64%, were receiving medication treatment at both time points. The most common reason given for why medication was discontinued were side effect experiences; this was reported by about 38% of parents whose child had discontinued treatment. Of those who had not been on medication initially, 90% were still not receiving it.

Although 100% of children who had been receiving school services continued to receive them, only 7% of children who had not been receiving services had begun to receive them in the intervening year. Over the 2-year period, therefore, only about a quarter of children with ADHD had received any specialized services at school.

The authors were also interested in identifying factors that predicted whether medication treatment or school services were received. Males were more than twice as likely to receive medication at either time point as females. In addition, medication treatment was more likely to be provided to children with higher levels of inattentive symptoms. Being African American and older increased the odds of receiving school services.

First, it is noteworthy that a roughly equal number of males and females in this representative community sample were identified as being at high risk of having ADHD. In sharp contrast to this finding, boys were more than twice as likely to receive medication treatment over the 2-year period covered by this study. Although not explicitly examined in this study, it is plausible to speculate that this occurred because the females diagnosed in this study - which did not include the provision of any treatment - were less likely to have been identified and treated by physicians in the community. As Drs. Patricia Quinn and Kathleen Nadeau have observed for many years, the under-identification and under-treatment of ADHD in girls continues to be an important issue. (To learn more about issues specific to ADHD in girls and women, visit the National Center for Gender Issues and ADHD at www.ncgiadd.org. A second noteworthy finding is that although academic struggles and underachievement are extremely common among children with ADHD, only about 28% of children with ADHD had access to specialized school-based services over the 2-year period. Although findings from a single geographic region cannot be generalized to the entire country, these data are consistent with other reports that many children with ADHD are not provided with the services at school to which they may be legally entitled. For additional information about the educational rights of children with ADHD, visit www.chadd.org/fs/fs4.htm

Finally, it is striking that despite widespread concern about the overmedication of children for ADHD, only about half the children in this sample received medication at any time over the 2-year period. Although non-optimal diagnostic evaluations may certainly contribute to the medication of children who do not have ADHD is also an important problem, it is important not to lose sight of the fact that many children who may benefit from this intervention never receive it.

In concluding their report, the authors suggest that "...few elementary school students receiving medication treatment for ADHD persistently receive such treatment over time." As reported above, over one third of the medication-treated children stopped ADHD medication use in the subsequent 12 months. Thus, in addition to the large percentage of children who received no medication treatment at all, many others discontinued treatment after a relatively short time period. As noted above, because ADHD tends to be a chronic condition, discontinuing treatment within a year is unlikely to result in any long-term benefits, even it is helpful during the time that it is implemented. Although results from this single community can not be generalized to the entire country, these data are consistent with findings of low persistence that have been reported in several other studies.

The authors also suggest that intervention for elementary school children with ADHD should target both increasing use and sustaining use over time of "nationally recommended treatments", i.e., medication and relevant school services, especially for girls. Although this is a reasonable conclusion to draw from the data they present, there are several other considerations that seem equally important.

First, it remains essential to document that high-quality, persistent medication treatment for ADHD can result in significant long-term benefits for children. Such benefits must extend beyond demonstrating reductions in core ADHD symptoms to include gains in important life outcomes such as academic success, social relationships, and occupational functioning. It is striking to note that although ADHD is by far the most widely research childhood psychiatric disorder, and there is at least one prior report in which important long-term benefits of medication treatment were suggested (Paternite et al., 1999. Childhood Inattention-Over activity, Aggression, and Stimulant Medication History as Predictors of Young Adult Outcomes. Journal of Child and Adolescent Psychopharmacology, 9, 169-184.), research to conclusively evaluate this most important of questions remains to be completed.

Second, a better understanding needs to be developed of why many parents discontinue medication treatment for their child within a year. This study provides some information on this important topic, and it appears that concerns over side effects is a frequently cited reason. However, other factors including concerns about effectiveness, loss of insurance coverage, etc., may also be quite important.

For parents who have opted to try medication for their child, but who are concerned by adverse side effects, it is important to be aware that adjusting the dose or the type of medication can often reduce or eliminate such adverse effects. When concerns emerge about the effectiveness of treatment, it is also important to note that such adjustments can also often yield better results. Thus, parents need to be aware that discontinuing treatment may not always be necessary and professionals should be vigilant about educating parents about the need to closely monitor children's treatment so that appropriate adjustments can be made when indicated.