Non-Pharmacologic Treatment Non-Pharmacologic Treatment for ADHD: What is the Evidence? for ADHD: What is the Evidence? Barbara Fitzgerald M.D. FRCP(C) Developmental Pediatrician Medical Director, Alderwood Family Development Centre Clinical Associate Professor UBC bfitzgerald@cw.bc.ca
Disclosures • on the Scientific Advisory Group of on the Scientific Advisory Group of Start to Finish which promotes Start to Finish which promotes exercise as a developmental support exercise as a developmental support for children for children • Member of CADDRA Member of CADDRA • No pharmaceutical industry No pharmaceutical industry sponsorship sponsorship
“ If I had an hour to solve all the problems of the world, I would spend 59 of those minutes defining the problem.” Albert Einstein
Learning Objectives • How we got here: revisiting the MTA study How we got here: revisiting the MTA study • Re-defining treatment goals for ADHD Re-defining treatment goals for ADHD • Explore evidence for some non-pharmacologic Explore evidence for some non-pharmacologic treatments available for ADHD treatments available for ADHD • Consider how we look at evidence for Consider how we look at evidence for different kinds of treatments different kinds of treatments
One important consideration when reviewing the literature • 1,560,000 results come up when you google 1,560,000 results come up when you google alternative treatments for ADHD alternative treatments for ADHD • In evidence based summaries, they refer to In evidence based summaries, they refer to evidence that a given treatment changes evidence that a given treatment changes ADHD symptoms; they don’t refer to a ADHD symptoms; they don’t refer to a treatment’s likelihood of altering function or treatment’s likelihood of altering function or long term outcomes. long term outcomes.
What is our intention? A. To manage the symptoms of inattention, A. To manage the symptoms of inattention, hyperactivity and impulsiveness. hyperactivity and impulsiveness. OR OR B. To improve long term outcomes related to B. To improve long term outcomes related to academic achievement, social integration, family academic achievement, social integration, family contentment and overall adjustment. contentment and overall adjustment.
Where we came from: The MTA study • In 1992, NIMH launched the Multimodal In 1992, NIMH launched the Multimodal Treatment Study of Children with ADHD Treatment Study of Children with ADHD 4 arms X 14 months: 4 arms X 14 months: 1. expert titrated stimulant medication 1. expert titrated stimulant medication 2. behavioural treatment: (both clinical behaviour 2. behavioural treatment: (both clinical behaviour therapy and direct contingency management) therapy and direct contingency management) 3. combination of medication and behavioural 3. combination of medication and behavioural treatment treatment 4. community-based treatment 4. community-based treatment
Initial findings from the MTA • Behavioural treatment plus medication is only Behavioural treatment plus medication is only slightly more efficacious than medication slightly more efficacious than medication alone, but not enough to justify the expense. alone, but not enough to justify the expense. • All groups improved over time • All groups improved over time (When using behaviour management plus (When using behaviour management plus medication, significantly lower doses of drugs medication, significantly lower doses of drugs could be used) could be used)
Repercussions of the MTA results • The finding that behavioural support is only The finding that behavioural support is only marginally better than medication alone has marginally better than medication alone has become a pillar of pharmaceutical companies’ become a pillar of pharmaceutical companies’ campaigns to market A.D.H.D. drugs. campaigns to market A.D.H.D. drugs. • used by government payers and school used by government payers and school systems to argue against therapies that are systems to argue against therapies that are usually more expensive than medication. usually more expensive than medication.
MTA findings continued… • Several years later, alternative analyses including more Several years later, alternative analyses including more reliable outcomes featuring functional impairment reliable outcomes featuring functional impairment indicated significant superiority for multimodal indicated significant superiority for multimodal intervention: significant incremental benefit from intervention: significant incremental benefit from adding behavioural treatment to medication adding behavioural treatment to medication • These results got far less media attention These results got far less media attention • 22 months after the end of formal treatment all four 22 months after the end of formal treatment all four treatment arms looked the same treatment arms looked the same • This pattern of initial superiority of medication This pattern of initial superiority of medication treatment that evaporated over time has continued treatment that evaporated over time has continued across all subsequent years of follow-up across all subsequent years of follow-up
MTA findings continued… “…the initial superiority of medication with “…the initial superiority of medication with respect to symptom improvement gradually respect to symptom improvement gradually abated after the randomly assigned interventions abated after the randomly assigned interventions ceased, becoming nonsignificant 2years later . At ceased, becoming nonsignificant 2years later . At the same time, certain side effects (e.g., a slight the same time, certain side effects (e.g., a slight diminution of ultimate adult height) persisted in diminution of ultimate adult height) persisted in some cases, leading to additional questions about some cases, leading to additional questions about the long-term advantages and disadvantages of the long-term advantages and disadvantages of pharmacologic intervention for ADHD.” pharmacologic intervention for ADHD.” (Swanson et al., Unpublished manuscript). (Swanson et al., Unpublished manuscript).
Clinical Result of the MTA • North American treatment guidelines featured North American treatment guidelines featured medication as the first line treatment (parallel medication as the first line treatment (parallel European recommendations did not) European recommendations did not) • These results led to significantly increased use • These results led to significantly increased use of stimulant medications in children. of stimulant medications in children. • Not much attention has been paid to the long Not much attention has been paid to the long term studies showing lack of efficacy of term studies showing lack of efficacy of medication on functional outcomes medication on functional outcomes
Treatment Subgroups: Aggressive Behaviour + ADHD: • the 54% of the MTA sample with comorbid the 54% of the MTA sample with comorbid diagnoses of aggressive behavior patterns diagnoses of aggressive behavior patterns (i.e., oppositional defiant disorder or conduct (i.e., oppositional defiant disorder or conduct disorder) did not show an appreciably disorder) did not show an appreciably different response to any of the four randomly different response to any of the four randomly assigned treatments. assigned treatments.
Treatment Subgroups: Group with significant parent improvement • The kids in the behaviour + medication group The kids in the behaviour + medication group whose parents improved the most had major whose parents improved the most had major improvements in school function improvements in school function
Treatment Subgroups: Anxiety + ADHD • the subgroup with ADHD plus a comorbid anxiety the subgroup with ADHD plus a comorbid anxiety disorder showed a better response to Behavioral disorder showed a better response to Behavioral Treatment and Combined Treatment than did Treatment and Combined Treatment than did those lacking such comorbidity. those lacking such comorbidity. • for youth with comorbid anxiety disorders, for youth with comorbid anxiety disorders, response to Behavioral Treatment was response to Behavioral Treatment was comparable to response to Medication comparable to response to Medication Management, and response to Combined Management, and response to Combined Treatment was even better. Treatment was even better.
Treatment Subgroups: Poverty+ADHD Families on welfare in the MTA trial: Families on welfare in the MTA trial: only Combined Treatment yielded meaningful only Combined Treatment yielded meaningful benefit with respect to the outcome of teacher- benefit with respect to the outcome of teacher- reported social skills. reported social skills.
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