ADHD treatments: are they meeting children's needs?

by **Nanneerose** Fri Apr 04, 2014 8:49 pm

As the number of children being diagnosed and treated for ADHD climbs, how can parents ensure their child gets the best treatment available?
ADHD treatments: are they meeting children's needs? Adhdtreatm_m2178441

ADHD treatments: are they meeting children's needs? Adhdtreatm_m2178441

ISTOCKPHOTO | WAVEBREAKMEDIA

With an increasing number of children being diagnosed with attention deficit hyperactivity disorder (ADHD), it's no surprise that we're also seeing more children being treated for the condition.
But concerns are also increasing about ADHD treatments – especially medications.
Last year the Therapeutic Goods Administration issued a safety warning in relation to atomoxetine (Strattera)after receiving reports of attempted suicides and an incident of suicide in young people taking the medication. ADHD treatments have also been linked to loss of appetite, poor weight gain, stomach pains, sleep disturbances, drowsiness, and depression. There is also evidence that children taking ADHD medications in the long-term may miss out on a centimetre or two of height.
Despite these issues, medication is a major component of ADHD treatment.
"If kids have moderate to severe ADHD which is causing significant functional impairment at home and school then there's no question that the best treatment is stimulant medication," says Dr Daryl Efron, consultant paediatrician at Melbourne's Royal Children's Hospital.
However, psychiatrist Professor Florence Levy from Sydney Children's Hospital and Prince of Wales Hospital says it can be hard to predict how individual children will respond to medication.
"One of the areas that we're doing research in is looking at genetic predictors of side effects and we published a study where we showed that a particular version of a particular gene – one of the dopamine receptor genes – could predict certain rigid, zombie-like side effects in certain children, whereas other children respond brilliantly," says Levy.
"The treatment needs to be tailored to the individual child and some may or may not develop side effects and need to be monitored."
Psychostimulants, such as methylphenidate (Ritalin), are the most common ADHD medication. These act to increase the amount of the neurotransmitter (or messenger chemical) dopamine available in the brain. They also help to increase levels of another neurotransmitter norepinephrine. While it's not entirely clear why or how drugs like methylphenidate work in ADHD, the evidence is clear that they do – at least in the short-term.
Intense reaction
Before the ABC screened a three-part documentary about Attention Deficit Hyperactivity Disorder (ADHD), called 'Kids on Speed?', director Marc Radomsky encountered intense reaction to the documentary – and particularly the title.
The documentary followed four families and five children suspected of, or who had been previously diagnosed with ADHD, and put them through a nine-week, evidence-based program to see if the children's behaviour improved.
"Before people saw the show they were responding just to the title which is deliberately contentious because it actually is the frame of the debate." There were concerns the title would offend parents of children with ADHD; while academics and the pharmaceutical industry were concerned it would drive people away from treatment.
Retraining parents
But medication is only one component of ADHD treatment. The National Health and Medical Research Council's Clinical Practice Points, which are the closest thing Australia has to treatment guidelines, recommend ADHD treatments be tailored to the specific needs of each child, and include either medication, psychological therapy and an educational program – or a combination of all three.
Psychologist Dr Rae Thomas, senior research fellow at the Center for Research in Evidence-Based Practice at Bond University, says psychological therapies are mostly aimed at parents and teachers.
"Parents need the skills to manage the behaviours as well so medication alone really shouldn't be the only option," says Thomas.
There are a number of evidence-based interventions that have been shown to help parents manage their child's ADHD symptoms – called parent management training. Thomas gives examples such as the Triple-P program, and Parent-Child Interaction Therapy (PCIT), which involves a psychologist watching the parent-child interaction through a one-way mirror and using an earpiece to instruct parents.
Thomas says these approaches are about retraining the parents rather than retraining the child.
"It would be very rare for me to see a child or early adolescent without parental involvement because if I don't train these people who are in charge of this child, what's the point?" Thomas says.
While parent management training has a strong evidence base behind it, it's not easy.
"We know we can change behaviour in eight weeks but it's maintaining it that's the problem," Thomas says. "It's like weight loss and cigarettes – it is extremely difficult to maintain the change."
Teachers' roles
Psychosocial therapy doesn't just involve parents. Efron says just as with diagnosing ADHD, it's vital that teachers are also given assistance in managing children with ADHD.
"In essence it's calm, good quality teaching and calm, good quality parenting," says Efron. "There's a whole range of strategies that we give parents to give to teachers for classroom management, we've developed a DVD for teachers, but always giving parents handouts to give to teachers to help them to make the classroom environment appropriate for kids."
Measures can include:

having the child sit closer to the teacher and away from possible distractions,
giving them regular breaks and frequent reminders about the tasks at hand,
giving them tasks with responsibility – such as collecting lunch orders – that can help with their self-esteem,
identifying any learning difficulties that might be causing the child's attention to drift.

Combined team effort
Levy agrees ADHD treatment has to be a combined, team effort, although sometimes access to appropriate treatment, particularly in schools, can be an issue.
"The basics are behavioural management plus or minus medication plus or minus remedial education where there's a learning problem," says Levy.
"I think sometimes learning problems can be overlooked or people can't afford to get the remediation or the schools can't provide the remediation but I think you need all three."
What works in the long-term?
But how effective are all these treatments in the long-term and what's their relative contribution to a child's improvement? A large US study called the Multimodal Treatment of Attention Deficit Hyperactivity Disorder (MTA) Study has been trying to answer this since the mid-1990s, and is still ongoing.
The results are mixed, says Efron.
"They found that for the core ADHD symptoms, such as concentration and impulse control, medication is by far and away the most effective treatment, much more effective than very intensive, very well monitored, very well structured behavioural programs for teachers and parents," he says.
"However, a lot of children with ADHD usually have other things going along, such as social problems and learning problems and emotional problems and so on, and behavioural strategies were often very helpful for those other things."
At the eight-year follow-up however, the picture had changed. Data published in 2007 showed the initial advantages of intensive medication – either alone or in combination with behavioural treatment – had largely disappeared.
Children who were no longer taking medication – which at the eight-year mark was nearly two-thirds of those who had been taking medication at the end of the first 14 months of the trial – were doing as well as those who were still taking their medication.
It raises the question of whether there are any advantages to long-term use of medication, particularly given some of the side effects associated with it.
Levy says much more research is needed to understand the mechanisms of ADHD so treatment can be better tailored to a child's needs.
"I'd like to see more money being put into research on both understanding the condition and on side effects which I think is also important because that then tells us what's going on in the children's brain circuits, with neurotransmitters, and predicting how a particular child will respond.
"I think that's the way medicine is heading in general, personalised approaches to treatment."
Asking for evidence
In the meantime, Thomas strongly encourages parents to demand evidence-based interventions when their child is diagnosed.
She says there are several questions they can ask their practitioner:

why are you choosing this treatment?
do you have any evidence that this works? (Thomas says it's worth adding "please don't tell me lots of my clients like it – show me some data.")
why will this work for my child?

"As a clinician, that's the first thing you've got to ask – not what is the diagnosis, but what are the problems and what strategies do I know that are evidence-based and that are clearly effective for this kind of problem?"
Efron says the MTA study data shows that we still have a way to go in our treatment options for ADHD.
"These findings indicate that although medication can be very helpful to reduce symptoms and help kids function well in the short-term, other strategies need to be used to help kids progress well academically and socially."
http://www.abc.net.au/health/features/stories/2014/03/24/3968142.htm

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