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Single and Combined Effects of Multiple Intensities of Behavioral Modification and Methylphenidate for Children with ADHD in the Home Setting

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Abstract

Behavioral treatment, stimulants, and their combination are the recommended treatments for childhood attention-deficit/hyperactivity disorder (ADHD). The current study utilizes within-subjects manipulations of multiple doses of methylphenidate (placebo, 0.15, 0.30, and 0.60 mg/kg/dose t.i.d.) and intensities of behavioral modification (no, low, and high intensity) in the summer treatment program (STP) and home settings. Outcomes are evaluated in the home setting. Participants were 153 children (ages 5–12) diagnosed with ADHD. In alignment with experimental conditions implemented during the STP day, parents implemented behavioral modification levels in three-week intervals, child medication status varied daily, and the orders were randomized. Parents provided daily reports of child behavior, impairment, and symptoms and self-reported parenting stress and self-efficacy. At the end of the study, parents reported treatment preferences. Stimulant medication led to significant improvements across all outcome variables with higher doses resulting in greater improvement. Behavioral treatment significantly improved child individualized goal attainment, symptoms, and impairment in the home setting and parenting stress and self-efficacy. Effect sizes indicate that behavioral treatment combined with a low-medium dose (0.15 or 0.30 mg/kg/dose) of medication results in equivalent or superior outcomes compared to a higher dose (0.60 mg/kg/dose) of medication alone. This pattern was seen across outcomes. Parents overwhelmingly reported preferring treatment with a behavioral component as a first-choice treatment (99%). Results underscore the need to consider dosing as well as parent preference when utilizing combined treatment approaches. This study provides further evidence that combining behavioral treatment and stimulant medication may reduce the stimulant dose needed for beneficial effects.

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Authors and Affiliations

  1. Center for Children and Families, Florida International University, Buffalo, NY, USA

    Brittany M. Merrill & Gregory A. Fabiano

  2. Center for Children and Families, Florida International University, Miami, FL, 33199, USA

    Fiona L. Macphee, Erika K. Coles, Jessica Robb Mazzant, Elizabeth M. Gnagy & William E. Pelham Jr.

  3. State University of New York at Buffalo, Buffalo, NY, USA

    Lisa Burrows-MacLean & Greta M. Massetti

  4. Department of Psychology, Ohio University, Athens, OH, USA

    Brian T. Wymbs

  5. Department of Applied Psychology, Steinhardt School of Culture, Education and Human Development, New York University, New York, NY, USA

    Anil Chacko

  6. The Downtown Psychology Clinic, Toronto, ON, Canada

    Kathryn Walker

  7. Department of Primary Care, Ohio University Heritage College of Osteopathic Medicine, Athens, OH, USA

    Frances Wymbs

  8. Department of Psychology, Kennesaw State University, Kennesaw, GA, USA

    Allison Garefino

  9. Department of Psychiatry, Pennsylvania State University Milton S. Hershey Medical Center, Hershey, PA, USA

    James G. Waxmonsky & Daniel A. Waschbusch

  10. Centers for Disease Control and Prevention, Atlanta, GA, USA

    Greta M. Massetti

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Funding

This research was funded by a grant from the National Institute of Mental Health (MH62946) and pre-registered at clinicaltrials.gov (NCT00050622). Dr. Pelham was also supported in part by grants from the National Institute of Mental Health (MH092466, MH53554, MH065899, MH62988), the Institute of Education Sciences (R37A120169 LO30000665A, R324B06045), the National Institute of Alcohol Abuse and Alcoholism (AA11873), the National Institute on Drug Abuse (DA12414, DA12986), and the National Institute of Child Health and Human Development (HD040935). James G. Waxmonsky has received research funding from the National Institutes of Health, Supernus, and Pfizer and served as a consultant for Adlon Therapuetics and Iron Shore Pharmaceuticals.

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Merrill, B.M., Macphee, F.L., Burrows-MacLean, L. et al. Single and Combined Effects of Multiple Intensities of Behavioral Modification and Methylphenidate for Children with ADHD in the Home Setting. Res Child Adolesc Psychopathol 51, 1481–1495 (2023). https://doi.org/10.1007/s10802-023-01093-6

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