Landmark NIMH ADHD study backed drugs over therapy at a cost

Many children with attention-deficit hyperactivity disorder (ADHD) may have missed out on valuable counseling because of a widely touted study that concluded stimulants such as Ritalin or Adderall were more effective for treating the disorder than medication plus behavioral therapies, experts say.

That 20-year-old study, funded with $11 million from the U.S. National Institute of Mental Health, concluded that the medications outperformed a combination of stimulants plus skills-training therapy or therapy alone as a long-term treatment.

But now experts, who include some of the study's authors, think that relying on such a narrow avenue of treatment may deprive children, their families and their teachers of effective strategies for coping with ADHD.

"I hope it didn't do irreparable damage," study co-author Dr. Lily Hechtman, of McGill University in Montreal, stated. "The people who pay the price in the end [are] the kids. That's the biggest tragedy in all of this."

Professionals worry that the findings have overshadowed the long-term benefits of school- and family-based skills programs.

The original findings also gave pharmaceutical companies a significant marketing tool—now more than two-thirds of American kids with ADHD take medication for the condition.

And insurers have also used the study to deny coverage of psychosocial therapy, which costs more than daily medication but may deliver longer-lasting benefits.

An insured family might pay $200 a year for stimulants, while individual or family therapy can be time-consuming and expensive, reaching $1,000 or more.

About 8 percent of U.S. children are diagnosed with ADHD before the age of 18, according to the U.S. Centers for Disease Control and Prevention.

People with the condition may have trouble paying attention, often act without thinking and may be hyperactive, making school work and the acquisition of essential skills extremely difficult.

Drugs that improve attention make it easier for the children to learn, but when the drug wears off or if the users stop taking the drugs, benefits are less apparent.

Some experts today cite limitations of the original study, which looked at classic ADHD symptoms such as forgetfulness and restlessness over academic achievement and family and peer interactions.

This gave medication an edge over therapy from the get-go, several people involved with the study reported.

"When you asked families what they really liked, they liked combined treatment," said Dr. Peter Jensen, formerly head of child psychiatry at the National Institute of Mental Health (NIMH) who oversaw the study for the 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."

For the study, the NIMH enlisted more than a dozen experts to determine the best ADHD treatment.

Close to 600 children with ADHD, aged 7 to 9, received one of four treatments for more than a year: medication alone, behavioural therapy alone, a combination of both treatments, or nothing in addition to their current treatment.

The study authors concluded in a 1999 paper that medication was superior to behavioural treatment.

But when the children in the study were followed into adulthood, the study results looked less conclusive.

Use of any treatment "does not predict functioning six to eight years later," a follow-up paper from the study determined, the Times reported.

'Back to sleep' does not affect baby's ability to roll

Baby, keep on rolling. A campaign to put babies to bed on their backs to reduce the risk of sudden infant death syndrome (SIDS) has not impaired infants' rolling abilities, according to University of Alberta research.

Johanna Darrah

Johanna Darrah, a professor of physical therapy in the Faculty of Rehabilitation Medicine, says infants develop the ability to roll much the same today as they did 20 years ago when the "back to sleep" campaign was introduced and successfully reduced the occurrence of SIDS.

Her research answers fears that the back to sleep campaign, which recommends putting babies to bed on their back instead of their stomach, would hurt an infant's gross motor development, specifically the ability to roll from tummy to back and vice versa.

"Infant gross motor development hasn't changed that much in 20 years," says Darrah.

"The thought that babies first roll from their tummy to their back, before they go from their back to their tummy, does not appear to be the case. For most babies, they happen very close together."

Darrah first studied infant motor development in the early 1990s as a graduate student of former dean Martha Cook Piper when the pair published the Alberta Infant Motor Scale, an observational assessment scale used throughout the world to measure infant motor skill development from birth to walking.

More than 20 years later, Darrah revisited the work, studying the rolling abilities and motor skills development of 725 Canadian infants ranging in age from one week to eight months.

One of her goals was to see whether the norms identified and developed 20 years ago still represent the age of emergence of gross motor skills.

Darah notes there is some concern in the physical therapy community that babies develop movement skills like rolling from tummy to back at later ages because of reduced time spent on their stomachs.

Those concerns appear to be unfounded, she says, explaining that her results are particularly valuable for health-care practitioners specializing in early childhood development.

"Our results would suggest that gross motor skills emerge in the same order and at the same ages as 20 years ago. The environment is of course important to gross motor development, but the change in a sleeping position hasn't made much difference as to when babies roll from stomach to back."