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A finding of beneficial combined low dose multimodal therapy has several important clinical implications. Side effects of stimulant medications are proposed to be related to dose, with higher doses producing significantly higher rates of associated side effects. It was reported that an alarmingly high 64% of children experienced acute side effects in the MTA study. Although purely speculative, previous research would provide some support for the contention that the ADHD children in the current study may have lower rates of side effects than studies prescribing higher doses of psychostimulants, including the MTA study (Pelham et al., 2005). Based on these findings, it should be

recommended that future intervention studies in children with ADHD routinely gather information on side effects of psychostimulants. Further to acute side effects, the long term risks of prolonged high dose psychostimulant use are also relatively unknown at present. However new evidence emerging from the MTA study suggests that

improvements associated with high doses of medications came at the cost of adverse effects to long term height and weight (MTA Cooperative Group, 2004). From a public health perspective, it would therefore appear sensible to promote the use of lower doses of medication in children with ADHD to minimise any potential short term and long term risks. Finally, anecdotal evidence would suggest that parents of ADHD children would also preferentially choose lower doses of psychostimulants for their child over the long term.

An interesting finding in the MTA study was the trend in their data showing that the combined group performed better than the other treatment groups on many of the

outcome measures. Although these trends didn’t reach statistical significance, the MTA Cooperative Group (1999) advised that lack of statistical significance should not be proof of equivalence of treatments nor should it indicate an absence of clinical significance. Put differently, although not consistently statistically superior, combined therapies have inherent advantages that make them clinically important treatments. For instance the MTA study reported that despite statistically being non-superior to medication alone

management, the parents in the combined treatment group reported significantly higher levels of satisfaction with the multimodal approach, with the implication being that parents felt happier with this mode of intervention. Parents reported that it helped them cope with the multitude of problems associated with ADHD, including problems that were perceived as not being improved with medication alone treatment, such as optimising family functioning. Also, an additive behavioural therapy component in a combined treatment approach can assist in controlling behaviour in the evenings when the effects of medication have perhaps dissipated and may be less effective. Finally, a combined therapy program might be more beneficial to those 30% of children with ADHD reportedly unresponsive to medication alone treatment. The inherent message here is that even if a combined therapy approach is not statistically superior or only modestly superior to medication management alone, it still produces significant improvements that may produce clinically significant changes.

Aside from the various benefits in combined therapy approaches overall, there are also several important aspects and advantages unique to the current study’s multimodal approach which may have played an important role in producing significant and modestly superior improvements in the present study. In contrast to past research, the current behavioural program was markedly less intensive and demanding than those implemented previously. The benefits of this design were two fold. Firstly, a brief and simple

behavioural therapy program is more ecologically valid, being achievable in the important context of standard clinical practice, not just being feasible in research. Secondly, this design is likely to be more appealing to families due to being minimally demanding on effort and time, in turn increasing adherence to the program. Furthermore, adherence to the behavioural program in the present study is likely strengthened by the individual nature of the treatment. Rather than attending numerous group sessions, each family received brief, but comprehensive, individualised psycho-education and guidance, with specific and relevant recommendations especially for their child. This was

conducted within a family systems framework. Therefore not only were parents involved, but primary caregivers were also included to ensure consistency and workability within the family context.

Another unique aspect of the current research was the decision to allow parents some choice over the treatment group their child was assigned to. Although perhaps not ideal from a random assignment point of view, this clinically driven approach parallels the decision making process in clinical practice, where parents ultimately decide upon treatment for their child. Moreover, Barkley (2000) argues that random assignment of children to treatment groups without consideration of parent’s choice may result in reduced effectiveness of behavioural programs, attributing this to parents not being ready to change.

In direct contrast, the behavioural components of each multimodal approach in the published literature encompasses an impressively intense and comprehensive program that is both complex and demanding for children, parents and teachers alike. Aside from being extremely intensive, time consuming and exceedingly expensive, the inherent nature of these programs lack sufficient ecological validity to be readily adaptable, let alone replicated, in any standard clinical context in the real world. Therefore these research based multimodal designs are generally incompatible, and not particularly relevant, to normal clinical practice. An additional criticism of many of the combined therapy intervention studies is the implementation of the group therapy “one size fits all” approach not tailored to the needs of the child or the family. To our knowledge, all existing empirical studies investigating multi-component treatments in children with ADHD subscribe to this intensive group therapy approach, a design no doubt useful for treating large numbers in research. However when one considers the heterogeneous nature of the disorder and the multitude of core and associated presenting problems, group therapy, as carried out in these research studies, may not permit a sufficiently individualised program necessary to address the specific needs of each child and family. More recent empirical work by Dopfner and colleagues (2004) and van der Ord et al., (2007) have attempted to address the lack of ecologically valid research by adopting designs more analogous to clinical practice. These studies reported beneficial effects of both combined treatment and medication alone in improving ADHD related behaviours,

however they unfortunately failed to explicitly compare the merits of their multimodal approaches directly with the psychostimulant treatment. Furthermore, even though treatment delivery in these studies was intended to more closely reflect those typically employed in normal clinical contexts, their behavioural programs remained group oriented, with the authors themselves advocating for briefer treatment programs more individualised for each child and family.

Even though the results of the current study are quite promising, the findings must be interpreted in light of the small number of participants in each treatment condition of the study. However in the presence of small participant numbers the robustness of the significant group findings and strong effect sizes in light of the stringent statistical control are undoubtedly impressive. Furthermore, it must be kept in mind that there was no group treatment program in this study, all treatment was individualised and performed separately for each child and family. Therefore the small numbers in the present study are somewhat justified by the individualised nature of the treatment program

implemented in this study.

An interesting, but non-significant, trend in the data was the tendency for the combined treatment group to be generally performing at a more impaired level across some of the outcome variables at baseline. Although not a statistically significant finding, it certainly could be argued that the children in the combined treatment group were overall more impaired and therefore could potentially be more responsive to treatment or gain more benefit from treatment. Although evidence exists in support of this notion (Rapport & Kelly, 1991), more recent findings emerging in the literature demonstrate that less impaired levels of baseline functioning may be associated with the greatest improvements in response to treatment (Bedard et al., 2002). The influence of baseline levels of performance and the differential effect of treatment need to be

investigated further before any conclusions can be confidently made about this effect. Future research would benefit from using teacher ratings to corroborate and extend the findings of the parent reports. Teacher ratings were not collected in the present study

for two reasons. Firstly, there is often poor compliance to research among teachers due to limited time and extensive workloads, with anecdotal evidence revealing very poor return rates of questionnaires. Secondly, children were followed up over six months, with consecutive assessments often running over into a new school year. This posed a problem of children not being consistently rated by the same teacher, with different raters potentially confounding the results.

Finally, there were no significant between subject effects, suggesting that although the combined group made greater improvements than the medication alone group across a range of outcome measures, there were no significant differences in performance scores at the final six month evaluation. It is extremely tempting to speculate, based on the presence of significant linear and quadratic trends in the data, that there might be an emerging trend for the combined group to demonstrate continued improvements with the medication group evidencing more of a plateau in performance. However without extended duration of follow-up, this proposed divergence in performance between the two groups is purely speculative. Although the treatment follow-up in the present study was comparable or even longer than many studies, it still remains far shorter than the average duration of treatment in standard clinical contexts. This only underscores the importance of extending treatment follow-up in intervention studies to be more comparable to that in normal practice.