I recently posted on the potential harms of overtreating ADHD and its overdiagnosis. Now, the NY Times reports on problems with a study that provided the foundation for the explosion on stimulant treatment for ADHD.
Twenty years ago, more than a dozen leaders in child psychiatry received $11 million from the National Institute of Mental Health to study an important question facing families with children with attention deficit hyperactivity disorder: Is the best long-term treatment medication, behavioral therapy or both?
The widely publicized result was not only that medication like Ritalin or Adderall trounced behavioral therapy, but also that combining the two did little beyond what medication could do alone. The finding has become a pillar of pharmaceutical companies’ campaigns to market A.D.H.D. drugs, and is used by insurance companies and school systems to argue against therapies that are usually more expensive than pills.
But in retrospect, even some authors of the study — widely considered the most influential study ever on A.D.H.D. — worry that the results oversold the benefits of drugs, discouraging important home- and school-focused therapy and ultimately distorting the debate over the most effective (and cost-effective) treatments.
The study was structured to emphasize the reduction of impulsivity and inattention symptoms, for which medication is designed to deliver quick results, several of the researchers said in recent interviews. Less emphasis was placed on improving children’s longer-term academic and social skills, which behavioral therapy addresses by teaching children, parents and teachers to create less distracting and more organized learning environments.
Recent papers have also cast doubt on whether medication’s benefits last as long as those from therapy.
The study’s primary paper, published in 1999, concluded that medication “was superior to behavioral treatment” by a considerable margin — the first time a major independent study had reached that conclusion. Combining the two, it said, “did not yield significantly greater benefits than medication” alone for symptoms of the disorder.
In what became a simple horse race, medication was ushered into the winner’s circle.
“Behavioral therapy alone is not as effective as drugs,” ABC’s “World News Now” reported. One medical publication said, “Psychosocial interventions of no benefit even when used with medication.”
Looking back, some study researchers say several factors in the study’s design and presentation to the public disguised the performance of psychosocial therapy, which has allowed many doctors, drug companies and schools to discourage its use.
First, the fact that many of the 19 categories measured classic symptoms like forgetfulness and fidgeting — over academic achievement and family and peer interactions — hampered therapy’s performance from the start, several of the study’s co-authors said.
A subsequent paper by one of those, Keith Conners, a psychologist and professor emeritus at Duke University, showed that using only one all-inclusive measurement — “treating the child as a whole,” he said — revealed that combination therapy was significantly better than medication alone. Behavioral therapy emerged as a viable alternative to medication as well. But his paper has received little attention.
“When you asked families what they really liked, they liked combined treatment,” said Dr. Peter Jensen, who oversaw the study on behalf of the mental health institute. “They didn’t not like medicine, but they valued skill training. What doctors think are the best outcomes and what families think are the best outcomes aren’t always the same thing.”
The parallels here are striking. The pattern is well established.
- Government involvement in the research gives the appearance of objectivity—”the National Institute of Mental Health gathered more than a dozen top experts on A.D.H.D. in the mid-1990s to try to identify the best approach”
- The study used outcome measures that favored medication—”The study was structured to emphasize the reduction of impulsivity and inattention symptoms, for which medication is designed to deliver quick results, several of the researchers said in recent interviews.”
- And de-emphasized outcome measures that favored behavioral treatments—”Less emphasis was placed on improving children’s longer-term academic and social skills, which behavioral therapy addresses”
- The biased study produces predictably biased outcomes—“Behavioral therapy alone is not as effective as drugs”
- Very biased outcomes—“Psychosocial interventions of no benefit even when used with medication.”
- The outcomes neglect real-world quality of life measures—”What doctors think are the best outcomes and what families think are the best outcomes aren’t always the same thing.”
- Studies with different findings were ignored—”The only thing we heard was the first finding — that medication is the answer”
- Medication doesn’t look so great in long term studies—”Using an additional $10 million in government support to follow the children in the study until young adulthood, researchers have seen some of their original conclusions muddied further.”
- Hindsight yields a little humility—”Most recently, a paper from the study said flatly that using any treatment “does not predict functioning six to eight years later,” leaving the study’s original question — which treatment does the most good long-term? — largely unanswered.”
- Hindsight also yields regrets—”I hope it didn’t do irreparable damage. The people who pay the price in the end is the kids.”
- Unfortunately, the genie is already out of the bottle—posts from earlier this month point to the potential harm, the selling of the diagnosis and the explosion in diagnosis.
- A.D.H.D. Experts Re-evaluate Study’s Zeal for Drugs (nytimes.com)
- The Selling of Attention Deficit Disorder (addictionandrecoverynews.wordpress.com)
- NY Times: A.D.H.D. Experts Re-Evaluate Zeal for Drugs (madinamerica.com)
- ADHD Experts Re-evaluate Zeal for Drugs (afterpartychat.com)