Ramin Rahimian for The New York Times
Stephen Hinshaw, a University of California, Berkeley, researcher in an influential 1990s study, said skills training should be a priority in A.D.H.D. cases.
Twenty years ago, more than a dozen leaders in child psychiatry received $11 million from the National Institute of Mental Health to study an important question facing families with children with attention deficit hyperactivity disorder: Is the best long-term treatment medication, behavioral therapy or both?
The widely publicized result was not only that medication like Ritalin or Adderall trounced behavioral therapy, but also that combining the two did little beyond what medication could do alone. The finding has become a pillar of pharmaceutical companies' campaigns to market A.D.H.D. drugs, and is used by insurance companies and school systems to argue against therapies that are usually more expensive than pills.
But in retrospect, even some authors of the study — widely considered the most influential study ever on A.D.H.D. — worry that the results oversold the benefits of drugs, discouraging important home- and school-focused therapy and ultimately distorting the debate over the most effective (and cost-effective) treatments.
The study was structured to emphasize the reduction of impulsivity and inattention symptoms, for which medication is designed to deliver quick results, several of the researchers said in recent interviews. Less emphasis was placed on improving children's longer-term academic and social skills, which behavioral therapy addresses by teaching children, parents and teachers to create less distracting and more organized learning environments.
Recent papers have also cast doubt on whether medication's benefits last as long as those from therapy.
"There was lost opportunity to give kids the advantage of both and develop more resources in schools to support the child — that value was dismissed," said Dr. Gene Arnold, a child psychiatrist and professor at Ohio State University and one of the principal researchers on the study, known as the Multimodal Treatment Study of Children With A.D.H.D.
Another co-author, Dr. Lily Hechtman of McGill University in Montreal, added: "I hope it didn't do irreparable damage. The people who pay the price in the end is the kids. That's the biggest tragedy in all of this."
A.D.H.D. narrowly trails asthma as the most frequent long-term medical diagnosis in children. More than 1 in 7 children in the United States receive a diagnosis of the disorder by the time they turn 18, according to the Centers for Disease Control and Prevention. At least 70 percent of those are prescribed stimulant medication like Adderall or Concerta because, despite potential side effects like insomnia and appetite suppression, it can quickly mollify symptoms and can cost an insured family less than $200 a year.
Comprehensive behavioral (also called psychosocial) therapy is used far less often to treat children with the disorder largely because it is more time-consuming and expensive. Cost-conscious schools have few aides to help teachers assist the expanding population of children with the diagnosis, which in some communities reaches 20 percent of students. Many insurance plans inadequately cover private or group therapy for families, which can cost $1,000 a year or more.
"Medication helps a person be receptive to learning new skills and behaviors," said Ruth Hughes, a psychologist and the chief executive of the advocacy group Children and Adults With Attention-Deficit/Hyperactivity Disorder. "But those skills and behaviors don't magically appear. They have to be taught."
Accepting no support from the pharmaceutical industry — "to keep it clean," Dr. Arnold said — the National Institute of Mental Health gathered more than a dozen top experts on A.D.H.D. in the mid-1990s to try to identify the best approach. Over 14 months, almost 600 children with the disorder ages 7 to 9 across the United States and Canada received one of four treatments: medication alone, behavioral therapy alone, the combination, or nothing beyond whatever treatments they were already receiving.
The study's primary paper, published in 1999, concluded that medication "was superior to behavioral treatment" by a considerable margin — the first time a major independent study had reached that conclusion. Combining the two, it said, "did not yield significantly greater benefits than medication" alone for symptoms of the disorder.
In what became a simple horse race, medication was ushered into the winner's circle.
"Behavioral therapy alone is not as effective as drugs," ABC's "World News Now" reported. One medical publication said, "Psychosocial interventions of no benefit even when used with medication."
Looking back, some study researchers say several factors in the study's design and presentation to the public disguised the performance of psychosocial therapy, which has allowed many doctors, drug companies and schools to discourage its use.
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