Kids' ADHD Care Gets a Wake-up Call 

 A combination of carefully monitored stimulant use and intensive behavioral training reaps promising benefits for children diagnosed with attention-deficit hyperactivity disorder (ADHD), as well as for their parents, according to a much-anticipated study of how best to treat the problem.

 However, the investigation also indicates that many kids with ADHD receive neither behavioral training nor careful dose calibrations for the stimulants that physicians prescribe.

"Standards of practice for ADHD treatment need to be improved," says psychologist Stephen P. Hinshaw of the University of California, Berkeley, one of the study's six principal investigators. "The level of care achieved in this project should be carefully considered by the medical community."

 Investigators at 10 sites in the United States and Canada recruited 579 children ages 7 to 10 with ADHD, many already getting stimulants. None suffered from depression or other ailments that can cause ADHD-like symptoms. The sample included 114 girls and 163 blacks and Hispanics. Family incomes for the children ranged from welfare level to affluent.

 The researchers randomly divided the children into four groups, giving them different treatments lasting up to 14 months. One group received behavioral therapy delivered by a specially trained psychotherapist, which included 35 weekly sessions to help parents deal with a child with ADHD; a summer camp designed to encourage kids' social and academic skills; and 10 to 16 meetings between a therapist and each child's teacher to plan classroom strategies.

 A second group underwent a medication program consisting of careful adjustment of a child's dose of Ritalin or a related stimulant over 28 days, followed by monthly physician visits and regular physician reviews of teachers' behavior ratings. Children took medication in three daily doses.

 A third group got both behavioral treatment and medication management.

 Finally, a comparison group received neither treatment from the study team, which referred the participants to community mental health providers. These physicians prescribed stimulants or, in a few cases, other drugs to two-thirds of the youngsters. A small number of participants sought some form of psychotherapy.

 Over 14 months, all four groups displayed marked reductions in ADHD symptoms, Hinshaw and his coworkers report in the December Archives of General Psychiatry. These consist of various signs of inattention, hyperactivity, and inability to control impulses.

 Medication management alone and the combined treatment yielded the most symptom improvement, with neither clearly being the best. However, combined treatment proved more effective at quelling aggressive behavior and boosting teacher-rated social skills and reading achievement. Parents in this group also reported the best relations with their child. These findings held regardless of sex, race, or family income.

 Further data analysis, set to appear in the Journal of Abnormal Child Psychology, indicates that school behavior improved most for kids in the combination group whose parents tempered their harsh disciplinary practices.

 Kids receiving stimulants from community sources typically did not undergo initial dose adjustments and took larger doses than those getting the study's medication-management or combination treatment.

 About two-thirds of the children receiving behavioral treatment alone did well enough to stay off medication throughout the study. "Psychosocial interventions can profoundly affect ADHD, even if a genetic predisposition is involved," Hinshaw contends.

 Further research needs to examine medication management and behavioral treatments in community settings, says psychologist Eric Taylor of the Institute of Psychiatry in London in a comment published in the same issue of Archives of General Psychiatry. Studies that modify exposure to behavioral treatment according to individual needs may yield steeper declines in ADHD symptoms, he proposes.