Drugs to treat attention-deficit hyperactivity disorder are no better at managing the condition than behavioural therapy in the long-term and can even stunt children’s growth, state claims made in the BBC’s Panorama programme.

The programme, which aired on TV last night, focused on follow-up research from the 1999 US-based Multimodal Treatment Study, which looked at different therapies in more than 600 children with the condition and was sponsored by the National Institute for Mental Health.

The first study found that treatment with stimulant drugs such as Novartis' Ritalin (methylphenidate) alone or in combination with behavioural therapy produced better outcomes after one year than just behavioural therapy or usual community care alone, which led to a massive uptake in ADHD drugs.

However, the follow-up trial found that these initial advantages declined in the years after the initial 14 months of controlled treatment ended, which has raised questions over the benefit-risk ratio of ADHD drugs, particularly as they can be associated with psychotic reactions and cardiovascular side effects.

“I think that we exaggerated the beneficial impact of medication in the first study,” MTA co-author, Professor William Pelham, told Panorama. “We had thought that children medicated longer would have better outcomes. That didn't happen to be the case,” he added, concluding: “There’s no indication that medication's better than nothing in the long run”.

Furthermore, he claims that taking medication could actually have a negative impact: "The children had a substantial decrease in their rate of growth so they weren't growing as much as other kids both in terms of their height and in terms of their weight”.

Incorrect assumptions
But after examining the 36-month outcomes, Peter Jensen from Columbia University and his colleagues stressed that “it would be incorrect to conclude from these results that treatment makes no difference or is not worth pursuing.”

Writing in the Journal of the American Academy of Child and Adolescent Psychiatry back in August, the researchers suggest a number of factors which could be behind the decline in this earlier advantage of having had 14 months of drug-based therapy, such as “an age-related decline in ADHD symptoms, changes in medication management intensity, starting or stopping medications altogether, or other factors not yet evaluated.”

Moreover, in a secondary analysis of the data led by James Swanson, University of California at Irvine, also published in the JAACAP, researchers reported substantial differences in individuals’ responses to medication, which could also impact the overall results and provides further evidence that results of the MTA follow-up are by no means clear cut.

And a Novartis spokesperson pointed out to PharmaTimes UK News: “Research shows medications such as Ritalin improve ADHD symptoms in up to 90% of children. Ritalin has been used safely and effectively in the treatment of ADHD over more than fifty years and is the most widely researched medication in the treatment of ADHD.”

She went on to stress that “management of ADHD may include a combination of behaviour modification, counselling and/or medication. It is up to the physician and those involved (adult patient or child caregivers) to discuss the various factors and determine the optimal treatment course for the individual”, and added that “the treatment plan needs to be reassessed and re-evaluated as a child grows older and symptoms and needs change.”

Furthermore, others have raised questions about the study’s relevance in today’s market. As a spokesperson for Shire, market leader for ADHD drugs in the USA, pointed out to PharmaTimes UK News, the MTA study began in 1999, and “things have moved on a lot since then.” The treatments being assessed were short-acting stimulants and not long-acting ones, and certainly aren’t the gold standard of therapy used today, she explained.

And commenting on the Panorama programme, a spokeswoman for the patient support group ADDISS told PharmaTimes she was disappointed with the “one-sided reporting” and that it “proved to be rather unhelpful for families hoping for answers”.

“The study’s findings were by no means conclusive, and are yet to be evaluated fully,” she said, adding: “We have had so many success stories of children taking ADHD treatments, and speak to many parents who say their children are doing very well on medication."

NHS spends £28m treating ADHD
Meanwhile, in the UK, the NHS current bill for ADHD therapies is fast approaching £30 million, according to Panorama, and the National Institute for Health and Clinical Excellence is currently reviewing its treatment guidelines for the condition.

It looks as if NICE’s approach will focus on a combination of therapies for the condition. The Institute’s Tim Kendall told the programme: "I hope that we will be able to make recommendations that will give people, based on the best evidence we've got, a comprehensive approach to treatment which will advise about the use of parent training programmes, the use of behavioural interventions…The important thing is that we have an approach which doesn't focus just on one type of treatment.”