NY Times
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. [...]
Medication helps a person be receptive to learning new skills and
behaviors,” said Ruth Hughes, a psychologist and the chief executive of
the advocacy group Children and Adults With Attention-Deficit/Hyperactivity Disorder. “But those skills and behaviors don’t magically appear. They have to be taught.”[...]
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. [...]
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.
“My belief based on the science is that symptom reduction is a good thing, but adding skill-building is a better thing,” said Stephen Hinshaw,
a psychologist at the University of California, Berkeley, and one of
the study researchers. “If you don’t provide skills-based training,
you’re doing the kid a disservice. I wish we had had a fairer test.”
