Journal of Abnormal Child Psychology

, Volume 42, Issue 6, pp 1019–1031 | Cite as

A Dose-Ranging Study of Behavioral and Pharmacological Treatment in Social Settings for Children with ADHD

  • William E. Pelham
  • Lisa Burrows-MacLean
  • Elizabeth M. Gnagy
  • Gregory A. Fabiano
  • Erika K. Coles
  • Brian T. Wymbs
  • Anil Chacko
  • Kathryn S. Walker
  • Frances Wymbs
  • Allison Garefino
  • Martin T. Hoffman
  • James G. Waxmonsky
  • Daniel A. Waschbusch
Article

Abstract

Placebo and three doses of methylphenidate (MPH) were crossed with 3 levels of behavioral modification (no behavioral modification, NBM; low-intensity behavioral modification, LBM; and high-intensity behavior modification, HBM) in the context of a summer treatment program (STP). Participants were 48 children with ADHD, aged 5–12. Behavior was examined in a variety of social settings (sports activities, art class, lunch) that are typical of elementary school, neighborhood, and after-school settings. Children received each behavioral condition for 3 weeks, order counterbalanced across groups. Children concurrently received in random order placebo, 0.15 mg/kg/dose, 0.3 mg/kg/dose, or 0.6 mg/kg/dose MPH, 3 times daily with dose manipulated on a daily basis in random order for each child. Both behavioral and medication treatments produced highly significant and positive effects on children’s behavior. The treatment modalities also interacted significantly. Whereas there was a linear dose–response curve for medication in NBM, the dose–response curves flattened considerably in LBM and HBM. Behavior modification produced effects as large as moderate doses, and on some measures, high doses of medication. These results replicate and extend to social-recreational settings previously reported results in a classroom setting from the same sample (Fabiano et al., School Psychology Review, 36, 195–216, 2007). Results illustrate the importance of taking dosage/intensity into account when evaluating combined treatments; there were no benefits of combined treatments when the dosage of either treatment was high but combination of the low-dose treatments produced substantial incremental improvement over unimodal treatment.

Keywords

ADHD treatment Behavior modification Methylphenidate Combined treatment Social behavior 

References

  1. Abikoff, H., Hechtman, L., Klein, R. G., Weiss, G., Fleiss, K., Etcovitch, J., et al. (2004). Symptomatic improvement in children with ADHD treated with long-term methylphenidate and multimodal psychosocial treatment. Journal of the American Academy of Child and Adolescent Psychiatry, 43, 802–811. doi:10.1097/01.chi.0000128791.10014.ac.PubMedCrossRefGoogle Scholar
  2. Abramowitz, A. J., Eckstrand, D., O'Leary, S. G., & Dulcan, M. K. (1992). ADHD children’s responses to stimulant medication and two intensities of a behavioral intervention. Behavior Modification, 16, 193–203. doi:10.1177/01454455920162003.PubMedCrossRefGoogle Scholar
  3. Carlson, C. L., Pelham, W. E., Milich, R., & Dixon, J. (1992). Single and combined effects of methylphenidate and behavior therapy on the classroom performance of children with ADHD. Journal of Abnormal Child Psychology, 20, 213–232. doi:10.1007/BF00916549.PubMedCrossRefGoogle Scholar
  4. Chronis, A. M., Pelham, W. E., Gnagy, E. M., Roberts, J. E., & Aronoff, H. R. (2003). The impact of late-afternoon stimulant dosing for children with ADHD on parent and parent–child domains. Journal of Clinical Child & Adolescent Psychology, 32, 118–126. doi:10.1207/S15374424JCCP3201_11.CrossRefGoogle Scholar
  5. Chronis, A. M., Fabiano, G. A., Gnagy, E. M., Onyango, A. N., Pelham, W. E., Williams, A., et al. (2004). An evaluation of the summer treatment program for children with attention-deficit/hyperactivity disorder using a treatment withdrawal design. Behavior Therapy, 35, 561–585. doi:10.1016/S0005-7894(04)80032-7.CrossRefGoogle Scholar
  6. DuPaul, G. J., & Eckert, T. L. (1997). The effects of school-based interventions for attention deficit hyperactivity disorder: a meta-analysis. School Psychology Review, 26, 5–27.Google Scholar
  7. Fabiano, G. A., Pelham, W. E., Waschbusch, D., Gnagy, E. M., Lahey, B. B., Chronis, A. M., et al. (2006). A practical impairment measure: psychometric properties of the impairment rating scale in samples of children with attention-deficit/hyperactivity disorder and two school-based samples. Journal of Clinical Child and Adolescent Psychology, 35, 369–385. doi:10.1207/s15374424jccp3503_3.PubMedCrossRefGoogle Scholar
  8. Fabiano, G. A., Pelham, W. E., Gnagy, E. M., Burrows-MacLean, L., Coles, E. K., Chacko, A., et al. (2007). The single and combined effects of multiple intensities of behavior modification and multiple intensities of methylphenidate in a classroom setting. School Psychology Review, 36, 195–216.Google Scholar
  9. Fabiano, G. A., Pelham, W. E., Coles, E. K., Gnagy, E. M., Chronis, A. M., & O’Connor, B. C. (2009). A meta-analysis of behavioral treatments for attention-deficit/hyperactivity disorder. Clinical Psychology Review, 29, 129–140. doi:10.1016/j.cpr.2008.11.001.PubMedCrossRefGoogle Scholar
  10. Hoza, B., Pelham, W. E., Sams, S. E., & Carlson, C. (1992). An examination of the “dosage” effects of both behavior therapy and methylphenidate on the classroom performance of two ADHD children. Behavior Modification, 16, 164–192. doi:10.1177/01454455920162002.PubMedCrossRefGoogle Scholar
  11. Hupp, S. D. A., Reitman, D., Northup, J., O’Callahan, P., & LeBlanc, M. (2002). The effects of delayed rewards, tokens, and stimulant medication on sportsmanlike behavior with ADHD-diagnosed children. Behavior Modification, 26, 148–162. doi:10.1177/0145445502026002002.PubMedCrossRefGoogle Scholar
  12. Jadad, A. R., Boyle, M., Cunningham, C., Kim, M., & Schachar, R. (1999). Treatment of attention-deficit hyperactivity disorder. Evidence Report/Technology Assessment No. 11. Rockville: Agency for Healthcare Research and Quality.Google Scholar
  13. Jensen, P. S., Arnold, L. E., Swanson, J. M., Vitiello, B., Abikoff, H. B., Greenhill, L. L., et al. (2007). 3-year follow-up of the NIMH MTA study. Journal of the American Academy of Child and Adolescent Psychiatry, 46, 989–1005. doi:10.1097/CHI.0b013e3180686d48.PubMedCrossRefGoogle Scholar
  14. Klein, R. G., & Abikoff, H. (1997). Behavior therapy and methylphenidate in the treatment of children with ADHD. Journal of Attention Disorders, 2, 89–114. doi:10.1177/108705479700200203.CrossRefGoogle Scholar
  15. Kolko, D. J., Bukstein, O. G., & Barron, J. (1999). Methylphenidate and behavior modification in children with ADHD and comorbid ODD or CD: main and incremental effects across settings. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 578–586. doi:10.1097/00004583-199905000-00020.PubMedCrossRefGoogle Scholar
  16. Loney, J., & Milich, R. (1982). Hyperactivity, inattention, and aggression in clinical practice. In M. Wolraich & D. K. Routh (Eds.), Advances in developmental and behavioral pediatrics (Vol. 3, pp. 113–147). Greenwich: JAI Press.Google Scholar
  17. MTA Cooperative Group. (1999a). 14-month randomized clinical trial of treatment strategies for attention deficit hyperactivity disorder. Archives of General Psychiatry, 56, 1073–1086. doi:10.1001/archpsyc.56.12.1073.CrossRefGoogle Scholar
  18. MTA Cooperative Group. (1999b). Moderators and mediators of treatment response for children with attention-deficit/hyperactivity disorder. Archives of General Psychiatry, 56, 1088–1096. doi:10.1001/archpsyc.56.12.1088.CrossRefGoogle Scholar
  19. MTA Cooperative Group. (2004). National Institute of Mental Health multimodal treatment study of ADHD follow-up: 24-month outcomes of treatment strategies for attention-deficit/hyperactivity disorder (ADHD). Pediatrics, 113, 754–761. doi:10.1542/peds.113.4.754.CrossRefGoogle Scholar
  20. Northup, J., Fusilier, I., Swanson, V., Huerte, J., Bruce, T., Freeland, J., et al. (1999). Further analysis of the separate and interactive effects of methylphenidate and common classroom contingencies. Journal of Applied Behavior Analysis, 32, 35–50. doi:10.1901/jaba.1999.32-35.PubMedCentralPubMedCrossRefGoogle Scholar
  21. O’Connor, B., Fabiano, G. A., Waschbusch, D. A., Belin, P. J., Gnagy, E. M., Pelham, W. E., et al. (2013). Effects of a summer treatment program on functional sports outcomes in young children with ADHD. Manuscript submitted for publication.Google Scholar
  22. Page, T., Fabiano, G., Greiner, A., Waxmonsky, J., Pelham W.E. III, Gnagy, E., et al. (2013). Comparative cost analysis of sequential, adaptive, behavioral, pharmacological, and combined treatments for ADHD. Manuscript submitted for publication.Google Scholar
  23. Pelham, W. E. (1993). Pharmacotherapy for children with attention-deficit hyperactivity disorder. School Psychology Review, 22, 199–227.Google Scholar
  24. Pelham, W. E. Jr., Burrows-MacLean, L., Massetti, G., Coles, E. K., Wymbs, B. T., Chacko, A., et al. (2013). Behavioral and pharmacological treatment for children with ADHD in the home setting. Manuscript submitted for publication.Google Scholar
  25. Pelham, W. E. Jr., Fabiano, G., Waxmonsky, J., Greiner, A., Gnagy, E., & Murphy, S. (2013). Treatment sequencing for ADHD: An adaptive, multiple-randomization study of medication and behavioral interventions. Manuscript submitted for publication.Google Scholar
  26. Pelham, W. E., & Fabiano, G. A. (2008). Evidence-based psychosocial treatment for attention deficit/hyperactivity disorder: an update. Journal of Clinical Child and Adolescent Psychology, 37, 185–214. doi:10.1080/15374410701818681.CrossRefGoogle Scholar
  27. Pelham, W. E., & Waschbusch, D. A. (1999). Behavioral intervention in ADHD. In H. C. Quay & A. Hogan (Eds.), Handbook of disruptive behavior disorders (pp. 255–278). New York: Plenum.CrossRefGoogle Scholar
  28. Pelham, W. E., Bender, M. E., Caddell, J., Booth, S., & Moorer, S. H. (1985). Methylphenidate and children with attention deficit disorder: dose effects on classroom academic and social behavior. Archives of General Psychiatry, 42, 948–952. doi:10.1001/archpsyc.1985.01790330028003.PubMedCrossRefGoogle Scholar
  29. Pelham, W. E., Greenslade, K. E., Vodde-Hamilton, M. A., Murphy, D. A., Greenstein, J. J., Gnagy, E. M., et al. (1990a). Relative efficacy of long-acting stimulants on children with attention deficit-hyperactivity disorder: a comparison of standard methylphenidate, sustained-release methylphenidate, sustained-release dextroamphetamine, and Pemoline. Pediatrics, 86, 226–237.PubMedGoogle Scholar
  30. Pelham, W. E., McBurnett, K., Harper, G. W., Murphy, D. A., Milich, R., Clinton, J., et al. (1990b). Methylphenidate and baseball playing in ADHD children: who’s on first? Journal of Consulting and Clinical Psychology, 58, 130–133. doi:10.1037/0022-006X.58.1.130.PubMedCrossRefGoogle Scholar
  31. Pelham, W. E., Gnagy, E. M., Greenslade, K. E., & Milich, R. (1992). Teacher ratings of DSM-III-R symptoms of the disruptive behavior disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 31, 210–218. doi:10.1097/00004583-199203000-00006.PubMedCrossRefGoogle Scholar
  32. Pelham, W. E., Carlson, C., Sams, S. E., Vallano, G., Dixon, M. J., & Hoza, B. (1993). Separate and combined effects of methylphenidate and behavior modification on boys with ADHD in the classroom. Journal of Consulting and Clinical Psychology, 61, 506–515. doi:10.1037/0022-006X.61.3.506.PubMedCrossRefGoogle Scholar
  33. Pelham, W. E., Greiner, A. R., & Gnagy, E. M. (1997). Summer treatment program manual. Buffalo: Comprehensive Treatment for Attention Deficit Disorders, Inc.Google Scholar
  34. Pelham, W. E., Lang, A. R., Atkeson, B., Murphy, D. A., Gnagy, E. M., Greiner, A. R., et al. (1998). Effects of deviant child behavior on parental alcohol consumption. The American Journal on Addictions, 7, 103–114. doi:10.1111/j.1521-0391.1998.tb00325.x.PubMedGoogle Scholar
  35. Pelham, W. E., Aronoff, H. R., Midlam, J. K., Shapiro, C. J., Gnagy, E. M., Chronis, A. M., et al. (1999). A comparison of Ritalin and Adderall: efficacy and time-course in children with attention-deficit/hyperactivity disorder. Pediatrics, 103. Retrieved from: http://www.pediatrics.org/cgi/content/full/103/4/e43.
  36. Pelham, W. E., Gnagy, E. M., Greiner, A. R., Hoza, B., Hinshaw, S. P., Swanson, J. M., et al. (2000). Behavioral vs. behavioral and pharmacological treatment in ADHD children attending a summer treatment program. Journal of Abnormal Child Psychology, 28, 507–526. doi:10.1023/A:1005127030251.PubMedCrossRefGoogle Scholar
  37. Pelham, W. E., Gnagy, E. M., Burrows-MacLean, L., Williams, A., Fabiano, G. A., Morrisey, S. M., et al. (2001). Once-a-day Concerta™ methylphenidate versus t.i.d. methylphenidate in laboratory and natural settings. Pediatrics, 107. Retrieved from: http://www.pediatrics.org/cgi/content/full/107/6/e105. doi: 10.1542/peds.107.6.e105.
  38. Pelham, W. E., Burrows-MacLean, L., Gnagy, E. M., Fabiano, G. A., Coles, E. K., Tresco, K. E., et al. (2005). Transdermal methylphenidate, behavioral, and combined treatment for children with ADHD. Experimental and Clinical Psychopharmacology, 13, 111–126. doi:10.1037/1064-1297.13.2.111.PubMedCrossRefGoogle Scholar
  39. Pelham, W. E., Gnagy, E. M., Greiner, A. R., Waschbusch, D. A., Fabiano, G. A., & Burrows-MacLean, L. (2010). Summer treatment programs for attention deficit/hyperactivity disorder. In J. R. Weisz & A. E. Kazdin (Eds.), Evidence-based psychotherapies for children and adolescents (2nd ed., pp. 277–292). New York: The Guilford Press.Google Scholar
  40. Poulton, A. (2005). Growth on stimulant medication; clarifying the confusion: a review. Archives of Disease in Childhood, 90, 801–806. doi:10.1136/adc.2004.056952.PubMedCentralPubMedCrossRefGoogle Scholar
  41. Scheffler, R. M., Hinshaw, S. P., Modrek, S., & Levine, P. (2007). The global market for ADHD medications. Health Affairs, 26, 450–457. doi:10.1377/hlthaff.26.2.450.PubMedCrossRefGoogle Scholar
  42. Stage, S. A., & Quiroz, D. R. (1997). A meta-analysis of interventions to decrease disruptive classroom behavior in public education settings. School Psychology Review, 26, 333–368.Google Scholar
  43. Subcommittee on Attention-Deficit/Hyperactivity Disorder, Steering Committee on Quality Improvement and Management. (2011). ADHD: Clinical practice guideline for the diagnosis, evaluation, and treatment of Attention-Deficit/Hyperactivity Disorder in children and adolescents. Pediatrics, 128, 2011–2654. doi:10.1542/peds.2011-2654.CrossRefGoogle Scholar
  44. Swanson, J. M., Elliott, G. R., Greenhill, L. L., Wigal, T., Arnold, L. E., Vitiello, B., et al. (2007). Effects of stimulant medication on growth rates across 3 years in the MTA follow-up. Journal of the American Academy of Child and Adolescent Psychiatry, 46, 1014–1026. doi:10.1097/chi.0b013e3180686d7e.Google Scholar
  45. Van der Oord, S., Prins, P. J. M., Oosterlan, J., & Emmelkamp, P. M. G. (2008). Efficacy of methylphenidate, psychosocial treatments and their combination in school-aged children with ADHD: a meta-analysis. Clinical Psychology Review, 28, 783–800. doi:10.1016/j.cpr.2007.10.007.PubMedCrossRefGoogle Scholar
  46. Waschbusch, D. A., Cunningham, C. E., Pelham, W. E., Rimas, H. L., Greiner, A. R., Gnagy, E. M., et al. (2011). A discrete choice conjoint experiment to evaluate parent preferences for treatment of young, medication naïve children with ADHD. Journal of Clinical Child and Adolescent Psychology, 40(4), 546–561. doi:10.1080/15374416.2011.581617.PubMedCentralPubMedCrossRefGoogle Scholar
  47. Wechsler, D. (1991). Wechsler intelligence scale for children (3rd ed.). San Antonio: The Psychological Corporation.Google Scholar
  48. Werry, J., & Sprague, R. (1974). Methylphenidate in children: effect of dosage. Australian and New Zealand Journal of Psychiatry, 8, 9–19. doi:10.3109/00048677409159770.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • William E. Pelham
    • 1
  • Lisa Burrows-MacLean
    • 2
  • Elizabeth M. Gnagy
    • 1
  • Gregory A. Fabiano
    • 2
  • Erika K. Coles
    • 1
  • Brian T. Wymbs
    • 3
  • Anil Chacko
    • 4
  • Kathryn S. Walker
    • 2
  • Frances Wymbs
    • 3
  • Allison Garefino
    • 5
  • Martin T. Hoffman
    • 2
  • James G. Waxmonsky
    • 1
  • Daniel A. Waschbusch
    • 1
  1. 1.Psychology and Psychiatry, Center for Children and Families MMCFlorida International UniversityMiamiUSA
  2. 2.University at Buffalo, The State University of New YorkBuffaloUSA
  3. 3.Ohio UniversityAthensUSA
  4. 4.City University of New YorkNew York CityUSA
  5. 5.Kennesaw State UniversityKennesawUSA

Personalised recommendations