Treatment Sequencing for Childhood ADHD: A Multiple-Randomization Study of Adaptive Medication and Behavioral Interventions

Abstract

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.

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