title: Treatment Sequencing for Childhood ADHD: A Multiple-Randomization Study of Adaptive Medication and Behavioral Interventions.
abstract: Behavioral and pharmacological treatments for children with attention deficit/hyperactivity disorder (ADHD) were evaluated to address whether endpoint outcomes are better depending on which treatment is initiated first and, in case of insufficient response to initial treatment, whether increasing dose of initial treatment or adding the other treatment modality is superior. Children with ADHD (ages 5-12, N = 146, 76% male) were treated for 1 school year. Children were randomized to initiate treatment with low doses of either (a) behavioral parent training (8 group sessions) and brief teacher consultation to establish a Daily Report Card or (b) extended-release methylphenidate (equivalent to .15 mg/kg/dose bid). After 8 weeks or at later monthly intervals as necessary, insufficient responders were rerandomized to secondary interventions that either increased the dose/intensity of the initial treatment or added the other treatment modality, with adaptive adjustments monthly as needed to these secondary treatments. The group beginning with behavioral treatment displayed significantly lower rates of observed classroom rule violations (the primary outcome) at study endpoint and tended to have fewer out-of-class disciplinary events. Further, adding medication secondary to initial behavior modification resulted in better outcomes on the primary outcomes and parent/teacher ratings of oppositional behavior than adding behavior modification to initial medication. Normalization rates on teacher and parent ratings were generally high. Parents who began treatment with behavioral parent training had substantially better attendance than those assigned to receive training following medication. Beginning treatment with behavioral intervention produced better outcomes overall than beginning treatment with medication.
authors.affiliation: a Center for Children and Families, Department of Psychology , Florida International University.
authors.forename: William E
authors.initials: WE
authors.lastname: Pelham
authors.affiliation: b Department of Counseling, School, and Educational Psychology , State University of New York at Buffalo.
authors.forename: Gregory A
authors.initials: GA
authors.lastname: Fabiano
authors.affiliation: c Department of Psychiatry, Pennsylvania State Hershey Medical Center , Pennsylvania State University.
authors.forename: James G
authors.initials: JG
authors.lastname: Waxmonsky
authors.affiliation: f Center for Children and Families , Florida International University.
authors.forename: Andrew R
authors.initials: AR
authors.lastname: Greiner
authors.affiliation: f Center for Children and Families , Florida International University.
authors.forename: Elizabeth M
authors.initials: EM
authors.lastname: Gnagy
authors.affiliation: d REACH Institute, Department of Psychology , Arizona State University.
authors.forename: William E
authors.initials: WE
authors.lastname: Pelham
authors.affiliation: a Center for Children and Families, Department of Psychology , Florida International University.
authors.forename: Stefany
authors.initials: S
authors.lastname: Coxe
authors.affiliation: g State University of New York at Buffalo.
authors.forename: Jessica
authors.initials: J
authors.lastname: Verley
authors.affiliation: g State University of New York at Buffalo.
authors.forename: Ira
authors.initials: I
authors.lastname: Bhatia
authors.affiliation: a Center for Children and Families, Department of Psychology , Florida International University.
authors.forename: Katie
authors.initials: K
authors.lastname: Hart
authors.affiliation: g State University of New York at Buffalo.
authors.forename: Kathryn
authors.initials: K
authors.lastname: Karch
authors.affiliation: g State University of New York at Buffalo.
authors.forename: Evelien
authors.initials: E
authors.lastname: Konijnendijk
authors.affiliation: h Department of Psychology , Philadelphia College of Osteopathic Medicine.
authors.forename: Katy
authors.initials: K
authors.lastname: Tresco
authors.affiliation: e Institute for Social Research , University of Michigan.
authors.forename: Inbal
authors.initials: I
authors.lastname: Nahum-Shani
authors.affiliation: i Institute for Social Research, Departments of Statistics and Psychiatry , University of Michigan.
authors.forename: Susan A
authors.initials: SA
authors.lastname: Murphy
mesh_terms: D001289:Attention Deficit Disorder with Hyperactivity / Q000175:diagnosis / Q000523:psychology* / Q000628:therapy*; D001521:Behavior Therapy / Q000379:methods*; D000697:Central Nervous System Stimulants / Q000008:administration & dosage*; D002648:Child; D015331:Cohort Studies; D003131:Combined Modality Therapy / Q000379:methods; D005260:Female; D006801:Humans; D008297:Male; D008774:Methylphenidate / Q000008:administration & dosage / Q000627:therapeutic use; D010290:Parents / Q000523:psychology*; D012017:Referral and Consultation; D000070777:School Teachers / Q000523:psychology*; D016896:Treatment Outcome
chemical_list: D000697:Central Nervous System Stimulants; D008774:Methylphenidate