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Do Comorbid Conditions Impact How Children with ADHD Respond to Treatment?
Many of you are already familiar with the results of the MTA study, the largest treatment study of ADHD every conducted. The goal of this study was to compare the effectiveness of carefully conducted medication treatment, intensive behavioral treatment, the combination of medication and behavioral treatment, and typical treatment for ADHD as practiced in community. Participants in this study were 579 children between the ages of 7 and 9.9 who had been carefully diagnosed with ADHD, Combined Type. Although children in all 4 treatment groups showed significant improvement, those in the medication-only group and the combined-treatment group had significantly greater improvement in their core ADHD symptoms than children given only intensive behavioral treatment or community care. There was also evidence that combined treatment provided a modest incremental benefit compared to careful medication treatment alone.
An important question not fully addressed in the initial analyses of the MTA results is whether treatment response may vary as a function of the other conditions a child may have in addition to ADHD (i.e. comorbid conditions). Unfortunately, it is well known that children with ADHD often have other conditions as well, including Oppositional Defiant Disorder (ODD), Conduct Disorder (CD), mood disorders, and anxiety disorders.
These comorbid conditions can complicate a child's treatment and tend to be associated with a poorer long-term prognosis. Therefore, it is very important to carefully examine whether the presence of these other difficulties affects the type of impairments that children have, how they respond to treatment, and the type of treatment that is likely to be most helpful. (Note: In the MTA study, medication and behavioral treatment were the only ones investigated because they are the interventions with the strongest empirical support at this time.)
These important question were examined in a recently published study titled "ADHD comorbidity findings from the MTA study: Comparing comorbid subgroups" (Jensen et al., (2001). Journal of the American Academy of Child and Adolescent Psychiatry, 40, 147-158).
In this report, the authors compared the treatment outcomes for 4 different groups of children from the MTS study: children with ADHD alone (n=184), children with ADHD and either ODD or CD but without an anxiety disorder (n=171), children with ADHD and an anxiety disorder but without ODD or CD (n=81), and children with ADHD, ODD/CD, and an anxiety disorder (n=143). (Note: Some of the children diagnosed with anxiety disorders had mood disorders as well.) Diagnoses and assignment to the different groups were based on structured psychiatric interviews conducted with parents, and thus do not reflect children's own reports of fears, worries, and other symptoms of anxiety.
Results
A number of different baseline and outcome measures were collected in this study, including core symptoms of ADHD, oppositional/aggressive behavior, academic achievement, anxiety and depression symptoms, social skills, and parent-child relations. Although the results varied across these different measures, there are several important general conclusions that can be made.
For these children with the most complex set of symptoms, overall outcome for combined treatment was significantly better than for either behavioral treatment or medication treatment alone.
Summary And Implications
These findings add substantially to the main results of the MTA study and have clinical implications that are potentially important for parents and clinicians. First, it appears that children with ADHD and a comorbid anxiety disorder may be especially likely to have concurrent academic problems and learning disabilities. Thus, for these children, it would be especially important for this possibility to be carefully considered and investigated. Although this is likely to occur in a comprehensive evaluation conducted by a child mental health specialist, this may be short-changed because of insurance-imposed limitations. In addition, primary care physicians may not always have the training that enables a careful assessment of academic functioning and learning difficulties to be completed.
Second, for children with ADHD and an anxiety disorder, carefully executed behavioral treatment may yield treatment gains that are equivalent to what would be provided by medication. Thus, in situations where parents have strong concerns about the use of medication, where children do not benefit from it, or, cannot tolerate it, behavioral treatment alone can be a reasonable treatment choice for these children. For these children, beginning treatment with behavior therapy alone and carefully monitoring their progress may alleviate the need for medication in many instances.
Third, parents and clinicians should be aware that in children with ADHD alone, or ADHD with ODD/CD, the use of carefully conducted medication therapy is likely to be especially critical. In the MTA study, these children did not respond well to medication treatment alone even though they showed robust responses to medication. When an anxiety disorder is also present, however, the addition of behavior treatment may confer some important incremental benefits.
As with any study, there are several important caveats to keep in mind. First, these results apply specifically to children with the combined subtype of ADHD between the ages of 7 and 10. The extent to which they would generalize to children with other ADHD subtypes (i.e. inattentive or hyperactive-impulsive) and of different ages is unknown. Second, there are always individual exceptions to results that are derived from comparing groups. Thus, although these results indicate what is more likely to be true about a specific child (e.g. a child with ADHD alone is likely to respond better to medication treatment than to behavioral treatment), there are always exceptions at the individual level.
Most importantly, the results from the MTA study are based on both medication and behavioral treatment that can be considered state-of-the-art. For example, children receiving medication treatment began with a careful placebo-controlled trial to determine their optimum starting dose, and were then carefully monitored each month to determine when modifications to dosage or even type of medication were necessary. Behavioral treatment included extensive work with parents, an 8-week summer program for children, and an intensive behavior management system at school.
Unfortunately, this is not the type of medication treatment or behavioral treatment that is typically provided in community settings. In fact, one of the main findings of the MTA study is that children receiving medication treatment or combined treatment in the study did significantly better than those whose treatment occurred in the community. Thus, one cannot assume, for example, that the behavior treatment most children have access to would show the same positive impact on children with ADHD and an anxiety disorder that was shown in this study.
Rather than being discouraged by this possibility, however, it is important for parents to learn as much as they can about what these state-of-the-art MTA treatments entailed, and to do their best to make sure that the treatment received by their child matches this to the extent possible. With medication treatment, for example, even though the entire placebo-controlled procedure would be hard to follow exactly, it is quite possible to incorporate several important elements of this procedure, including testing a child on a full range of doses, obtaining systematic feedback from teachers on the child's behavior and school work on each dose, and obtaining such feedback on a regular basis to determine when treatment modifications may be necessary. These simple steps can make an important difference.
I'd encourage you to use the monitoring system that I developed and that is currently offered for FREE by Attention.com that can help parents and health care providers track a child's ongoing response to treatment and determine when adjustments may be necessary.
Note: This article originally appeared in Attention Research Update, an online newsletter written by Dr. David Rabiner, a Duke University psychologist and former member of CHADD's Professional Advisory Board. You can learn more about Attention Research Update and sign up for a free subscription at www.helpforadd.com.