Objective: To assess, in hyperactive children: 1) relative efficacy of behavior therapy, methylphenidate, and their combination; 2) effects of methylphenidate withdrawal after combined treatment; and 3) normalization effects of the combination.
Method: Eighty-nine children were randomly assigned to treatment for eight weeks. Children on the combined treatments were switched to a placebo, double-blind. Ratings from parents, teachers and clinicians, and school observations were obtained.
Results: Parents and teachers viewed children on behavior therapy as improved, but objective observations did not document behavioral change. In contrast, methylphenidate and the combined treatment induced significant improvement in all measures of outcome. Methylphenidate and the combination treatments were significantly superior to behavior therapy. In a few instances, the combination, which normalized behavior, was superior to methylphenidate. Children switched to placebo deteriorated significantly.Discussion:Behavior therapy delivered in school and home is not nearly as effective as methylphenidate for ADHD, but may be a useful adjunct to methylphenidate.
Get full access to this article
View all access options for this article.
References
1.
Abikoff, H., Ganeles, D. , Reiter, G., Blum, C., Foley, C., & Klein, R.G. (1988). Cognitive training in academically deficient ADDH boys receiving stimulant medication . Journal of Abnormal Child Psychology, 16, 411-432.
2.
Abikoff, H., & Gittelman, R. (1984). Does behavior therapy normalize the behavior of hyperactive children? Archives of General Psychiatry, 41, 449-454.
3.
Abikoff, H., & Gittelman, R. (1985b). Hyperactive children treated with stimulants: Is cognitive training a useful adjunct? Archives of General Psychiatry, 42, 953-961.
4.
Abikoff, H., & Gittelman, R. (1985a). The normalizing effects of methylphenidate on the classroom behavior of ADDH children. Journal of Abnormal Child Psychology, 13, 33-44.
5.
Abikoff, H., Gittelman, R. , & Klein, D.F. ( 1980). A classroom observation code for hyperactive children: A replication of validity. Journal of Consulting and Clinical Psychology, 48, 555-565.
6.
Abikoff, H., Gittelman-Klein, R., & Klein, D.F. ( 1977). Validation of a classroom observation code for hyperactive children. Journal of Consulting and Clinical Psychology, 45, 772-783.
7.
American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders, Fourth Edition. Washington, DC: American Psychiatric Association.
8.
Armstrong, T. (1995). The Myth of the ADD Child. New York, NY: Dutton.
9.
Bradley, C. (1937). The behavior of children receiving benzedrine. American Journal of Psychiatry , 94, 577-585.
10.
Becker, W.C. (1971). Parents are teachers: A child management program. Champagne, IL : Research Press.
11.
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 attention-deficit hyperactivity disorder. Journal of Abnormal Child Psychology, 20, 213-232.
12.
Conners, C.K. (1969). A teacher rating scale for use in drug studies with children. American Journal of Psychiatry, 126, 884-888.
13.
Conners, C.K. (1970). Symptom patterns in hyperkinetic, neurotic and normal children. Child Development, 41, 667-682.
14.
Eysenck, N.T., & Rachman, S.T. (1971). The application of learning theory to child psychiatry. In T.C. Howells (Ed.), Modern perspectives in child psychiatry (pp. 104-169). New York, NY: Brunner/Mazel.
15.
Firestone, P., Kelly, M.J. , Goodman, J.T., & Davey, J. (1981). Differential effects of parent training and stimulant medication with hyperactives. Journal of the American Academy of Child Psychiatry, 20, 135-147.
16.
Gittelman, R., Abikoff, H. , Pollack, E., Klein, D.F., Katz, S., & Mattes, J. (1980). A controlled trial of behavior modification and methylphenidate in hyperactive children . In C. Whalen, & B. Henker (Eds.), Hyperactive children: The social ecology of identification and treatment (pp. 221-243). New York, NY: Academic Press.
17.
Gittelman-Klein, R., Klein, D.F., Katz, S., Saraf, K., & Pollack, E. (1976b). Comparative effects of methylphenidate and thioridazine in hyperkinetic children. I. Clinical results. Archives of General Psychiatry, 33, 1217-1231.
18.
Gittelman-Klein, R., Klein, D.F., Abikoff, H., Katz, S., Gloisten, A.C. , & Kates, W. (1976 a). Relative efficacy of methylphenidate and behavior modification in hyperkinetic children: An interim report. Journal of Abnormal Child Psychology, 4, 361-379.
19.
Grinspoon, L., & Singer, S.B. (1973). Amphetamine in the treatment of hyperkinetic children. Harvard Educational Review, 43, 515-554.
20.
Hechtman, L., & Abikoff, H. (1995, October). Multimodal treatment plus stimulants vs. stimulant treatment in ADHD children: Results from a two-year comparative treatment study. Paper presented at the annual meeting of the American Academy of Child and Adolescent Psychiatry, New Orleans, LA.
21.
Hersen, M. (1979). Limitations and problems in the clinical application of behavioral techniques in psychiatric settings. Behavior Therapy, 10, 65-80.
22.
Hinshaw, S. P., & Erhardt, D. (1993). Behavioral treatment. In V.B. Van Hasselt & M. Hersen (Eds.), Handbook of behavior therapy and pharmacotherapy for children: A comparative analysis (pp. 233-250). Needleham Heights, MA: Allyn & Bacon.
23.
Hinshaw, S.P., Klein, R.G. , & Abikoff, H. (in press). Childhood attention-deficit hyperactivity disorder: Nonpharmacologic and combination treatments. In P. Nathan & J. Gorman (Eds.), Treatments that work. New York, NY: Oxford University Press.
24.
Horn, W.F., Ialongo, N.S. , Pascoe, J.M., Greenberg, G.A., Packard, T., Lopez, M., Wagner, A., & Puttler, L. (1991). Addictive effects of psychostimulants, parent training, and self-control therapy with ADHD children. Journal of the American Academy of Child and Adolescent Psychiatry, 30, 233-240.
25.
Ialongo, N.S., Horn, W.F. , Pascoe, J.M., Greenberg, G., Packard, T., Lopez, M., Wagner, A., & Puttler, L. (1993). The effects of a multimodal intervention with attention-deficit hyperactivity disorder children: A 9-month follow-up. journal of the American Academy of Child and Adolescent Psychiatry, 32, 182-189.
26.
Kagan, J., Rosman, B.L., Day, D., Albert, J., Phillips, W. (1964). Information processing in the child: Significance of analytic and reflective attitudes . Psychology Monographs, 78, 1-37.
27.
Klein, D.F., Gittelman, R. , Quitkin, F., & Rifkin, A. (1980). Diagnosis and drug treatment of psychiatric disorders: Adults and children. Baltimore, MD: Williams & Wilkins.
28.
Klein, R.G. (1987). Pharmacotherapy of childhood hyperactivity : An update. In H.Y. Meltzer, W. Bunney, J. Coyle, K. Davis, I. Kopin, C.R. Schuster, R.I. Shader, & G. Simpson (Eds.), Psychopharmacology: The third generation of progress (pp. 1215-1224). New York, NY: Raven Press.
29.
Klein, R.G., Landa, B., Mattes, J.A., & Klein, D.F. (1988). Methylphenidate and growth in hyperactive children: A controlled withdrawal study. Archives of General Psychiatry, 45, 1127-1130.
30.
Kohn, A. (1989, November). Suffer the restless children. The Atlantic Monthly, 90-100.
O'Leary, K.D., & O'Leary, S.G. (1972). Classroom management in the successful use of behavior modification. New York, NY: Pergamon Press.
34.
O'Leary, K.D., Pelham, W.E. , Rosenbaum, A., & Price, G.H. (1976). Behavioral treatment of hyperkinetic children: An experimental evaluation of its usefulness . Clinical Pediatrics, 15, 274-279.
35.
Patterson, G.R. (1975). Families: Applications of social learning to family life. Champagne, IL: Research Press.
36.
Patterson, G.R., & Guillion, M.E. (1971). Living with children : New methods for parents and teachers. Champagne, IL: Research Press.
37.
Pelham, W.E., Carlson, C. , Sams, S.E., Dixon, M.J., & Hoza, B. (1993). Separate and combined effects of methylphenidate and behavior modification on boys with attention-deficit hyperactivity disorder in the classroom. Journal of Consulting and Clinical Psychology , 61, 506-515.
38.
Pelham, W.E., & Hinshaw, S.P. (1992). Behavioral intervention for attention-deficit hyperactivity disorder. In S.M. Turner, K.S. Calhoun, & H.E. Adams (Eds.), Handbook of clinical behavior therapy (2nd ed.) (pp. 259-983). New York, NY: John Wiley.
39.
Pelham, W.E., Jr., & Murphy, D.A. (1986). Attention deficit and conduct disorders. In M. Hersen (Ed.), Pharmacological and behavioral treatment: An integrative approach (pp. 108-148). New York, NY: John Wiley.
40.
Pelham, W.E., & Murphy, D.A. (1995). Attention deficit disorder. In D. Byrne & G. Caddy (Eds.), Behavioral medicine. International perspectives (Vol. III) (pp. 261-309) Norwood, NJ : Ablex Publishing.
41.
Pelham, W.E., Schnedler, R.W., Bender, M., Nilsson, D., Miller, J. , Budrown, M., Ronnei, M., Paluchowski, C., & Marks, D. (1988). The combination of behavior therapy and methylphenidate in the treatment of attention deficit disorder: A therapy outcome study. In. L.M. Bloomingdale (Ed.), Attention deficit disorder (Vol. 3) (pp. 29-48). Oxford , United Kingdom: Pergamon.
42.
Pisterman, S., McGrath, P. , Firestone, P., Goodman, J.T., Webster, I., Mallory, R. (1989 ). Outcome of parent-mediated treatment of preschoolers with attention deficit disorder with hyperactivity. Journal of Consulting and Clinical Psychology , 57, 628-635.
43.
Pollack, E., & Gittelman, R. (1981) Practical problems encountered in behavioral treatment with hyperactive children. In M. Gittelman (Ed.), Strategic interventions for hyperactive children (pp. 160-177). Armonk, NY: M.E. Sharpe.
44.
Rapport, M.D., Denney, C. , DuPaul, G.J., & Gardner, M.J. (1994). Attention deficit disorder and methylphenidate: Normalization rates, clinical effectiveness, and response prediction on 76 children. Journal of the American Academy of Child and Adolescent Psychiatry, 33, 882-893.
45.
Robinson, P.W., Newby, T.J. , & Ganzell, S.L. ( 1981). A token system for a class of underachieving hyperactive children. Journal of Applied Behavior Analysis, 14, 307-315.
46.
Ross, D.M., & Ross, S.A. (1982). Hyperactivity: Current issues, research, and theory (2nd ed.). New York, NY: John Wiley.
47.
Sandberg, S., Day, R., & Trott, G.E. (1996). Clinical Aspects. In S. Sandberg (Ed.), Hyperactivity disorders of childhood (pp. 69-110). New York, NY: Cambridge University Press.
48.
Schachar, R., Tannock, R. , & Cunningham, C. ( 1996). Treatment. In S. Sandberg (Ed.), Hyperactivity disorders of childhood (pp. 433-476). New York, NY: Cambridge University Press.
49.
Sprague, R.L. (1983). Behavior modification and educational techniques. In M. Rutter (Ed.), Developmental neuropsychiatry (pp. 404-421). New York, NY: Guilford Press.
50.
Sprague, R.L., Christensen, D.E., & Werry, J.S. ( 1974). Experimental psychology and stimulant drugs. In C.K. Conners (Ed.), Clinical use of stimulant drugs in children (pp. 141-163). The Hague: Excerpta Medica.
51.
Sprague, R.L., & Werry, J.S. (1971). Methodology of psychopharmacological studies with the retarded. In N.R. Ellis (Ed.), International review of research in mental retardation (Vol. 5) (pp. 147-219). New York, NY: Academic Press.
52.
Sroufe, L.A., & Stewart, M.A. (1973). Treating problem children with stimulant drugs. New England journal of Medicine, 289, 407-413.
53.
Werry, J. (1968). Developmental hyperactivity. Pediatric Clinics of North America, 15, 581-599.
54.
Wolraich, M., Drummond, T. , Salomon, M., O' Brien, M., & Sivage, C. (1978). Effects of methylphenidate alone and in combination with behavior modification procedures on the behavior and academic performance of hyperactive children. Journal of Abnormal Psychology, 6, 149-161.
55.
Rachel G. Klein, PhD is with the New York State Psychiatric Institute and Columbia University College of Physicians and Surgeons; Howard Abikoff, PhD is with the New York University Medical Center.
