(PS11-B40) Does Concurrent Stimulant Medication Have an Adverse Impact on the Effectiveness of Intensive Behavioral Treatment for Children with ADHD?

Despite decades of research supporting the short-term effectiveness of psychostimulants (MED), behavioral treatments (BT), and the combination of the two (Pelham & Altszuler, 2020) for youth with ADHD, long-term prognosis remains poor, even when multimodal treatment has been acutely effective (Hechtman et al., 2016). One potential explanation is that the function of MED treatment for children with ADHD is to eliminate a very high percentage of the child’s behavior problems typically targeted in BT interventions thereby dramatically and paradoxically reducing the number of opportunities for the teacher and parent to learn and provide either positive or negative consequences for the child’s behavior and therefore the number of learning opportunities for both the child (e.g., self-regulation) and the adult (i.e., behavior management strategies). The present study presents preliminary data of a recently completed within-subject, cross-over study examining the effect of tolerance to stimulant medication (MH099030) within the context of an intensive BT program (STP; Pelham et al., 2017). Participants included 248 elementary-aged children diagnosed with ADHD, who were predominantly male (69.9%) and of Hispanic origin (84.2%). Following a two-week MED titration period and adjustment to BT, participants were then randomized to their optimum dose of stimulant medication in combination with intensive BT (COMB) or to a placebo (BT alone) during weeks 3-5 of the STP. Participants then crossed over to the other condition for weeks 6-8 of STP. Despite intensive BT (the standard intervention in the STP) occurring concurrently and being consistently implemented, on average children randomized COMB first showed significantly higher levels of negative verbalizations (Daily Mean: 6.9; range 0 to 146) when switched to placebo (BT alone) than did the children who received placebo in the three weeks of intensive BT (Daily Mean: 12.6; range 0 to 381). That is, children who were receiving active medication (MED) during weeks 3-5 of treatment and thus behaved better during those weeks had a “rebound” and worse behavior when medication was replaced with a placebo during weeks 6-8 of the STP. Comparison of the plots in Figure 1 offer strong preliminary support for the notion that despite an acute salutary effect from concurrent medication (vs placebo), a combined treatment approach had a subsequent substantial negative impact on the functioning of children with ADHD when medication was withdrawn. These results suggest that concurrent stimulant medication in the early weeks of BT (in this case for 5 weeks in an STP) appears to undermine the impact of BT.