Objective
Behavioral and pharmacological treatments for children with ADHD were evaluated to address whether endpoint outcomes are better depending on which treatment is initiated first, and, in case of insufficient response to initial treatment, whether increasing dose of initial treatment or adding the other treatment modality is superior.
Methods
Children with ADHD (ages 5–12, N = 146, 76% male) were treated for one school year. Children were randomized to initiate treatment with low doses of either (a) behavioral parent training (8 group sessions) and brief teacher consultation to establish a Daily Report Card or (b) extended-release methylphenidate (equivalent to .15 mg/kg/dose bid). After 8 weeks or at later monthly intervals as necessary, insufficient responders were rerandomized to secondary interventions that either increased the dose/intensity of the initial treatment or added the other treatment modality, with adaptive adjustments monthly as needed to these secondary treatments.
Results
The group beginning with behavioral treatment displayed significantly lower rates of observed classroom rule violations (the primary outcome) and parent/teacher ratings of oppositional behavior at study endpoint and tended to have fewer out-of-class disciplinary events. Further, adding medication secondary to initial behavior modification resulted in better outcomes on the primary outcomes and other measures than adding behavior modification to initial medication. Normalization rates on teacher and parent ratings were generally high. Parents who began treatment with behavioral parent training had substantially better attendance than those assigned to receive training following medication.
Conclusions
Beginning treatment with behavioral intervention produced better outcomes overall than beginning treatment with medication.
Stimulant medication and behavioral treatments are evidence-based for children with attention-deficit/hyperactivity disorder, but the combination of the 2 treatments has been understudied. In this investigation, methylphenidate (MPH) was crossed with 2 levels of behavior modification (BMOD) in a summer treatment program. Twenty-seven children with attentiondeficit/hyperactivity disorder, aged 6 -12, participated. Children received placebo and 3 doses of transdermal MPH (12.5 cm 2 , 25.0 cm 2 , and 37.5 cm 2 ). BMOD was implemented on alternating weeks. Both treatments produced large and significant effects. Combined treatment was superior to either treatment alone. The effects of transdermal MPH were comparable to those found in this setting in previous studies with multiple stimulant medications and formulations. Consistent with other research, low doses of MPH-even lower than in previous studies-yielded enhanced effects in combination with behavior modification.
The purpose of this investigation was to evaluate the relative efficacy of two consultation-based models for designing academic interventions to enhance the educational functioning of children with attention-deficit/hyperactivity disorder (ADHD). Children (N=167) meeting DSM-IV criteria for ADHD were randomly assigned to one of two consultation groups: Individualized Academic Intervention (IAI; interventions designed using a data-based decision-making model that involved ongoing feedback to teachers) and Generic Academic Intervention (GAI; interventions designed based on consultant-teacher collaboration, representing "consultation as usual"). Teachers implemented academic interventions over 15 months. Academic outcomes (e.g., standardized achievement test, and teacher ratings of academic skills) were assessed on four occasions (baseline, 3 months, 12 months, 15 months). Hierarchical linear modeling analyses indicated significant positive growth for 8 of the 14 dependent variables; however, trajectories did not differ significantly across consultation groups. Interventions in the IAI group were delivered with significantly greater integrity; however, groups did not differ with respect to teacher ratings of treatment acceptability. The results of this study provide partial support for the effectiveness of consultation-based academic interventions in enhancing educational functioning in children with ADHD; however, the relative advantages of an individualized model over "consultation as usual" have yet to be established.
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