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The multimodal
treatment study of 540 attention deficit hyperactivity disorder (ADHD) patients
reported the intent-to-treat analyses of 7 to 9 year old subjects who were
treated for up to 24 months. Four naturalistic subgroups were formed in
accordance with their patterns of medication intake over 2 periods: the first
14 months and during the 14-24 month period (Med/Med, Med/NoMed, NoMed/Med and
NoMed/NoMed). Exploratory mediator analysis was performed to assess the effects
of changes of medication intake, changes in scores of medication effectiveness
(symptom ratings of 5 conceptually distinct domains of function) and growth
(height and weight measures). The behavioral effectiveness of the medication
use was greatest among children who ingested medications throughout the
24-month observation period. Those who stopped taking their medication and/or
those who never received it showed increasing behavioral problems. However,
there was significant growth deterioration among those who took medication for
the longest periods. Between the Med/Med group and the NoMed/NoMed group the
mean difference at the end of 24 months was –1.94 cm in height growth
suppression, being similar in the 2 periods of observation. The weight gain
changes were larger during the initial phase (–2.5 kg) than during the second
period (–1.22 kg). Similar growth deterioration was observed in the 2 other
groups while they received medication, with improvement during the NoMed
periods. The authors concluded that consistent treatment with stimulant
medication was associated with maintenance of behavioral effectiveness but
continued growth suppression.
MTA Cooperative Group. National Institutes of Mental Health multimodal treatment study of ADHD follow-ups: changes in effectiveness and growth after the end of treatment. Pediatrics 2004;113:762-769.
Editor’s Comment: This paper is difficult to
read; however, it provides important data obtained with sophisticated
methodologies and statistical analyses. The cooperative group clearly
documented behavioral benefits of ADHD treatment, but there were consequences
of the stimulant medication on growth as well as substantial difficulties in
compliance. The high rate of patients who did not adhere to the drug regimen
allowed the formation and assessment of 4 naturalistic groups. It has long been
debated whether these medications alter growth progression; this study clearly
demonstrated that they do. The growth-suppression effect persisted as long as
the medications were ingested. This study also provided evidence that treatment
interruption limits growth-suppression effects. The somewhat larger body weight
deterioration that was observed might be due to the anorexic effects of these
medications. Suboptimal nutrition appears to be an underlying cause of reduced
growth, an aspect that should be thoroughly investigated. For a particular ADHD
patient with growth concerns, when the stimulant cannot be interrupted, the
physician should attempt to overcome the decreased dietary intake and correct
nutrient deficits to foster appropriate growth. The pediatric endocrinologist
is increasingly seeing more of these patients and should be aware of this
important paper.
Fima Lifshitz, MD
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Current GGH - Vol. 24 No. 1
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