'Drugs 'of no benefit' to hyperactive children'

Drugs given to hyperactive children offer no long-term benefit reported three newspapers (12 November 2007). The newspapers were generally accurate in their reporting of findings from a three year follow-up study following a randomised clinical trial. The studies conclusions appear reliable.

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Three newspapers (1-3) reported that drugs such as Ritalin and Concerta, which are prescribed to children with attention deficit hyperactivity disorder (ADHD) offer no long-term benefit. The newspaper reports were previewing an edition of the BBC Panorama programme (4) due to be aired on Monday.
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The reports are largely based on research referred to in an edition of the BBC programme Panorama. The programme discussed findings from four research papers published in the Journal of the American Academy of Child & Adolescent Psychiatry from the Multimodal Treatment Study of Children with ADHD (5-8). This Hitting the Headlines article focuses on the results relating to the three year follow-up of the MTA study, a randomised clinical trial which assessed four different treatment options for children with ADHD (5). The authors reported that all of the intervention groups (medical and behavioural treatments alone or in combination; usual community care) showed improvement in clinical outcomes at three years compared to baseline. However there was no significant difference in clinical outcomes between these treatment groups. The authors surmised that this could be due to an age-related decline in ADHD or changes in the use of medication during the follow-up period.
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All the newspapers reported the main finding of the study accurately. However, no newspaper reported that all treatment groups showed an improvement in clinical outcomes from baseline.

Evaluation of the evidence base for the long-term effects of behavioural and medication treatments for children with ADHD
Where does the evidence come from?

The evidence comes from the Multimodal Treatment Study of Children with ADHA (MTA) which was conducted by collaborators working for the National Institute of Mental Health and was led by Dr Peter Jensen.
What were the authors' objectives?

To assess the long-term effects of behavioural and medication treatments for children with ADHD.
What was the nature of the evidence?

This was a three year follow-up report assessing long-term outcomes for 485 children who were included in an earlier randomised clinical trial of children diagnosed with ADHD. Most of the children included in the study were male aged between 10 to 13 years at three year follow-up. The primary clinical outcomes of interest were parent and teacher rated ADHD symptoms; parent and teacher rated oppositional defiant disorder (ODD); parent and teacher social skills rating; Wechsler Individual Achievement Test reading score and overall functional impairment. Other outcomes assessed were diagnostic status using the Diagnostic Interview Schedule for Children IV and service use.
What interventions were examined in the research?

In the original randomised clinical trial the children were given either behavioural therapy, medical management, combined behavioural therapy and medical management or routine community care for 14 months. The study did not include any untreated control group.

After 14 months the children were able to receive any treatment based on availability and personal preference, regardless of what they were originally randomised to receive.
What were the findings?

At three year follow-up there was no significant difference in primary outcomes between children who received some form of medical management and children who received behavioural therapy or routine community care.

There was no significant difference in ADHD diagnosis between the intervention groups at three year follow-up.

At three year follow-up all of the intervention groups showed improvement from baseline in primary outcomes.

After the initial 14 month trial, medication use rates began to converge: decreasing medical management groups and increasing in the behavioural management group.
What were the authors' conclusions?

By 36 months the earlier advantage of 14 months medication was no longer apparent, possibly due to age-related decline in ADHD symptoms or changes in medication compliance/adherence or intensity.
How reliable are the conclusions?

The authors set out a clear objective and study outcomes were defined and determined a priori. Not enough information was provide to assess the quality of the original RCT however the four intervention groups were comparable at baseline in terms of important characteristics that could influence the results. The children followed up at three years appeared to be similar on key characteristics to those lost to follow-up. The statistical analysis adopted appears appropriate and the authors investigated the effects of co-morbidity factors. The authors also acknowledge that a limitation of the study was the uncontrolled use of behavioural therapy and medical intervention once the trial ended. Despite the limitations of the study the authors' conclusions are likely to be reliable.
Systematic reviews

Information staff at CRD searched for systematic reviews relevant to this topic. Systematic reviews are valuable sources of evidence as they locate, appraise and synthesize all available evidence on a particular topic.

There were no related systematic reviews identified on the Cochrane Database of Systematic Reviews (CDSR), however there were eight on the Database of Abstracts of Reviews of Effects (DARE) (9-16).
References and resources

1. Drugs 'of no benefit' to hyperactive children. Daily Telegraph, 12 November 2007, p10.

2. Danger drugs designed for schizophrenics used to calm children of ten. Daily Mail, 12 November 2007, p6.

3. Hyperactivity drugs 'stunt children's growth'. Daily Express, 12 November 2007, p17.

4. BBC. What Next for Craig? Panorama [Online]. 2007 Nov 12 [cited 2007 Nov 12]. Available from: http://news.bbc.co.uk/1/hi/programmes/panorama/7079233.stm.

5. Jensen PS, Arnold LE, Swanson JM, Vitiello B, Abikoff HB, Greenhill LL, et al. 3-year follow-up of the NIMH MTA study. Journal of the American Academy of Child & Adolescent Psychiatry 2007;46(8):989-1002.

6. Swanson JM, Hinshaw SP, Arnold LE, Gibbons RD, Marcus S, Hur K, et al. Secondary evaluations of MTA 36-month outcomes: propensity score and growth mixture model analyses. Journal of the American Academy of Child & Adolescent Psychiatry 2007;46(8):1003-14.

7. Swanson JM, Elliott GR, Greenhill LL, Wigal T, Arnold LE, Vitiello B, et al. Effects of stimulant medication on growth rates across 3 years in the MTA follow-up. Journal of the American Academy of Child & Adolescent Psychiatry 2007;46(8):1015-27.

8. Molina BSG, Flory K, Hinshaw SP, Greiner AR, Arnold LE, Swanson JM, et al. Delinquent behavior and emerging substance use in the MTA at 36 months: prevalence, course, and treatment effects. Journal of the American Academy of Child & Adolescent Psychiatry 2007;46(8):1028-40.

9. Klassen A, Miller A, Raina P, Lee SK, Olsen L. Attention-deficit hyperactivity disorder in children and youth: a quantitative systematic review of the efficacy of different management strategies. Canadian Journal of Psychiatry 1999;44(10):1007-16. [DARE Abstract]

10. Silva RR, Munoz DM, Alpert M. Carbamazepine use in children and adolescents with features of attention-deficit hyperactivity disorder: a meta-analysis. Journal of the American Academy of Child & Adolescent Psychiatry 1996;35(3):352-8. [DARE Abstract]

11. McGoey KE, Eckert TL, DuPaul GJ. Early intervention for preschool-age children with ADHD: a literature review. Journal of Emotional and Behavioral Disorders 2002;10(1):14-28. [DARE Abstract]

12. Faraone SV, Biederman J. Efficacy of Adderall for attention-deficit/hyperactivity disorder: a meta-analysis. Journal of Attention Disorders 2002;6(2):69-75. [DARE Abstract]

13. Schachter HM, Pham B, King J, Langford S, Moher D. How efficacious and safe is short-acting methylphenidate for the treatment of attention-deficit disorder in children and adolescents: a meta-analysis. Canadian Medical Association Journal 2001;165(11):1475-88. [DARE Abstract]

14. Gilmore A, Milne R. Methylphenidate in children with hyperactivity: review and cost-utility analysis. Pharmacoepidemiology and Drug Safety 2001;10(2):85-94. [DARE Abstract]

15. Purdie N, Hattie J, Carroll A. A review of the research on interventions for attention deficit hyperactivity disorder: what works best. Review of Educational Research 2002;72(1):61-99. [DARE Abstract]

16. Jadad AR, Boyle M, Cunningham C, Kim M, Schachar R. Treatment of attention-deficit/hyperactivity disorder. 1999:341. Rockville, MD, USA: Agency for Health Care Policy and Research. [DARE Abstract]

17. King S, Griffin S, Hodges Z, Weatherly H, Asseburg C, Richardson G, et al. A systematic review and economic model of the effectiveness and cost-effectiveness of methylphenidate, dexamfetamine and atomoxetine for the treatment of attention deficit hyperactivity disorder in children and adolescents. Health Technol Assess 2006;10(23).