Transcript
Announcer:
Welcome to NeuroFrontiers on ReachMD. On this episode, we’re joined by Dr. James Swanson, who’s a Professor of Pediatrics at the University of California, Irvine School of Medicine and Founder of the Child Development Center at UC Irvine. He’ll be sharing findings from his recent work, entitled, “Long-Term Outcomes in the Multimodal Treatment Study of Children with ADHD (MTA) from Beginning to End (and Beyond).” Let’s hear from Dr. Swanson now.
Dr. Swanson:
The MTA study was remarkable. I was very pleased and to be able to be part of this study, which was initiated by Peter Jensen and Eugene Arnold and others at NIMH in the 1990s. At that time, there were many hundreds of randomized trials of stimulant medication to document the efficacy of treatment, and the effect size in meta-analyses was clear even then: around 0.8, which is a very large effect.
But the MTA was a randomized trial, and over time, we documented that the effect would last longer than the typical randomized trial of that era, around three to four, maybe even five months. So we extended that to a year, and we documented long-term effectiveness in a randomized trial, the gold standard.
And as we continued to follow up these children, the effect decreased. Most people stopped using medication—about 50 percent in childhood and 75 percent in adolescents, and 90 percent or 95 percent by adulthood. And even in those who continued to use medication, we couldn't demonstrate in these observational studies with appropriate adjustments any long-term effect. That is just unacceptable. There are a lot of individuals with ADHD. They need treatment. They need treatment not just in the short term, but they need effective treatment in the long term.
And my understanding is that there is, really, an enduring absence of evidence of long-term benefit of the use of stimulant medication to treat ADHD, and I just don't accept that. I think we need to do studies to identify why that might occur and try to deal with this—try to meet these needs that are unmet of a medication that will maintain its efficacy over decades, not just over months.
It's very odd that at each assessment of the follow-up of the MTA, after the randomized trial that lasted 14 months, we followed up on either a one or two-year basis, and at each assessment, about 50 percent of the children no longer met criteria for ADHD. And that held up for 16 years. The complexity was that it wasn't always the same children that had shown remission.
The children seemed to wax and wane in terms of their symptom manifestation. They would show remission, and then they would show recurrence. So almost 90 percent of the children in the MTA over the 16 years showed remission at some point. And I think the critical thing that is really important is, how do we maintain that benefit over time, over the lifetime of a child and through adolescence and into adulthood?
Now, that doesn't mean that some children, a subgroup, did not benefit in the long term over the whole 16 years, because some did. But the number who did was rather low, and it's odd that at the endpoint, about 50 percent of the children still had ADHD. They were not in remission, and 50 percent were. But an equal percentage of those children were still being treated with medication, even though many stopped. Only about five or 10 percent were still using medication. It was equally split between those with and without ADHD and remission.
That's odd. It's not something I understand. And children with ADHD who continued to manifest symptoms had poorer outcomes, but they also showed a larger response to the medication in the long term, and that is the complexity that I understand is shown by the MTA, which is a remarkable study—one of a kind. It hasn't been duplicated in 20 or 30 years. It should be. It hasn't. And that is a complex nuance that I think clinicians need to appreciate.
Announcer:
That was Dr. James Swanson discussing recent findings from the long-term follow-up of the Multimodal Treatment Study of ADHD. To access this and other episodes in our series, visit NeuroFrontiers on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!
