PHOENIX — Using behavioral interventions for attention-deficit/hyperactivity disorder delayed the start of medication and reduced the dose needed in a randomized, controlled study of 127 schoolchildren.
The study is the first to use behavioral modification before initiating medication for attention-deficit/hyperactivity disorder (ADHD), Erika K. Coles, Ph.D., said at a meeting of the New Clinical Drug Evaluation Unit sponsored by the National Institute of Mental Health.
The researchers also took the unusual approach of basing the need for medication on measures of impairment, not symptoms, and separated treatment of the disorder at school from treatment at home.
The study enrolled children aged 5–12 years who had participated in a tightly controlled 9-week summer treatment program and research study of three intensities of behavior modification and four doses of medication for ADHD. All of the students started the school year unmedicated.
Dr. Coles and her associates randomized them to follow-up with or without behavioral consultation. The behavioral consultations started with three meetings with teachers and parents, often before school started, to set up behavioral intervention plans and daily report cards to track success and identify problems.
Children randomized to the behavioral modification group went longer into the school year before starting methylphenidate either in school or at home and were significantly less likely to use the drug at home (24%), compared with those who did not get behavioral consultations (of whom 53% took methylphenidate at home).
By the end of the school year, the proportion of children who had started the drug did not differ significantly between groups (70% in the behavioral modification group and 80% in the control group), but the average weekly dose of methylphenidate was significantly lower in the behavioral intervention group (157 mg/day), compared with the control group (234 mg/day), said Dr. Coles, an assistant professor of psychology at the University of Maine, Orono.
In both groups, teachers and parents completed a weekly Impairment Rating Scale for seven domains of functioning such as academics, getting along with peers or family, interrupting the classroom, and more.
In the control group, a spike in teacher or parent ratings of impairment triggered a medication assessment for initiation of short-acting methylphenidate. In the behavioral modification group, a ratings spike triggered an emergency consultation to try to adjust the behavioral plan. If parents or teachers remained concerned about a child's impairment for 2 more consecutive weeks, a medication assessment began.
The only factor that predicted that a child would start medication was a history of methylphenidate use prior to the summer program, a finding that surprised the investigators. “We looked at socioeconomic status, comorbidity, and other factors—nothing else predicted it,” Dr. Coles said.
Before the summer program, 77% of the cohort had taken medication at school for ADHD. Of these, 17% also had taken medication at home.
Among children who went on medication at school during the study, parents opted for weekend medication as well for 18% in the behavioral consult group and 56% in the control group, a significant difference.
The idea that the need for medication can be determined separately for school and home could counter a trend toward use of longer-acting doses of methylphenidate.
“This study is starting to show that doesn't necessarily have to be true. You can reduce the amount of medication if you just medicate [when] children are impaired,” she said, adding that many studies of behavioral interventions for ADHD focus on reducing symptoms and may miss the benefits of reducing impairment.
Dr. Coles has no association with makers of ADHD treatments.