Where we are, and how well we can succeed, at treating ADHD

Focus on ADHD Where we are, and how well we can succeed, at treating ADHD By Harlan R. Gephart, MD At pediatricians' disposal today are numerous formulations of approved medications for ADHDtraditional psychostimulants and newer agents. We also have developed an appreciation of the value of a multipronged approach to this chronic disorder. In the century since what we now call attention deficit hyperactivity disorder (ADHD) first was described, our understanding of this condition has changed. We also have gained new knowledge about how best to treat ADHD. Looking back ADHD was probably first described in 1902 by British pediatrician and scholar, Dr. George Still.1 Early descriptions centered more on what was thought to be the condition's cause, which included "post-encephalitic syndrome" or "minimal brain damage." Later terminologyfor example "the hyperactive child" or "attention-deficit disorder"focused more on naming the major symptoms than on the etiologya logical development because what was presumed to be the etiology often had no basis in fact. Specific treatment for what we now call ADHD began with the work of Bradley. In 1937, he documented improvement in the behavior of hyperactive children who were given racemic amphetamine (benzedrine).2 Bradley's work lay dormant until the 1950s and 60s, when there was a resurgence of stimulant medication trials, first with amphetamines and then with methylphenidate.3,4 Since then, amphetamines and methylphenidate have been staples for treating the core ADHD symptoms of hyperactivity, impulsivity, and inattention. The psychostimulants were the only medications approved by the US Food and Drug Administration (FDA) for ADHD until last year,5,6 when the nonstimulant atomoxetine was approved. Getting it right Psychostimulants are indeed highly effective for treating ADHD. Taken alone, either methylphenidate or amphetamine controls symptoms in about 70% of children with ADHD.6 Taken successively (if one hasn't worked, try the other), the success rate is 90%, or better.7 In addition to controlling core ADHD symptoms, the psychostimulants also improve related symptoms, such as aggressiveness and oppositional behavior,8 that make the child with ADHD so difficult to live with. For this reason, parents were unhappy when, in the past, physicians recommended so-called drug holidays for their child (not giving medication on weekends and summer vacations); in fact, they often ignored that recommendation. Decades of experience with thousands of patients has provided no significant evidence that psychostimulants are associated with harmful long-term side effects, making the drug holiday outdated and irrelevant. We also know now that the placebo effect of psychostimulants is short lived and not clinically significant.9 In other words, performing a placebo trial of a psychostimulant medication to determine its effectiveness is unnecessary; simply start the patient on a low dosage and titrate upward at five- to seven-day intervals (more about this later). Last, we now have many psychostimulant medications from which to choose. Methylphenidate and the amphetamines are available in various forms and in formulations that last not only four to eight hours but up to 12 hours, and beyond. This greatly improves our ability to provide smooth medication delivery throughout the patient's day, without the inconvenience of peaks and valleys, a noon dose at school, and missed doses because of noncompliance. Some of these newer dosage forms are almost impossible to abuse, which eliminates a major objection that parents have to psychostimulant medication. Goals of treatment What do we want to accomplish when we treat ADHD? We seek to: alleviate the core symptoms of ADHD (e.g., diminish overactivity, inattentiveness, and impulsive behavior) lessen accompanying behaviors (e.g., oppositional behavior, compliance problems) help the child achieve normal peer and family relationships enhance academic successby increasing attention and performance and by recognizing and remediating learning problems recognize and treat any coexisting conditions that interfere with successful treatment improve organizational skills and overall executive functioning enhance self-esteem Given the lofty nature of these goals, it isn't surprising that medication alone is inadequate to achieve them. (Yet, regrettably, most patients with ADHD in this country are being treated with medicine only.) Medication cannot, for example, treat underlying learning difficulties, even though it makes the child more attentive, more "teachable," and more available for the learning process. Similarly, organizational skills and improved executive functioning must be learned and brought into the patient's own system of self-accommodation. And, of course, medications are not curative: They work only as long as they are taken, and when they are no longer taken, the symptoms return immediately. Taking a multimodal approach The multimodal approach to ADHD does not minimize the important contribution of medication to the overall treatment program.10 Rather, it incorporates other important treatment modalities. The principal components of the multimodal treatment program for ADHD are: parent education educational intervention behavioral therapy medication Parent education. The parents of a child with ADHD need to be instructed about the underlying nature, prognosis, and treatment of their child's disorder. A diagnosis of ADHD often makes parents feel depressed or guilty, or that they have failed as parents. In addition to reassuring parents that their child's condition is not their fault, the clinician must educate them about what ADHD really is and how they can successfully raise their child. It's fortunate that many educational resources are available for parents, including books, organizations, and Web sites (see the box). Educational interventions. Children with ADHD often struggle mightily in school. Completion of work, time management, study skills, remembering when assignments are due, taking tests, and understanding instructions are a few of the school-related skills that are affected by this disorder. In addition, the impulsive or disruptive behavior associated with ADHD often gives rise to conflict with peers and school personnel. Children with ADHD are more likely to have a coexisting learning disability than are other children. Writing is particularly difficult for these children; their poor fine-motor skills compound the problem. Interestingly, some children write more legibly after they begin taking medication, not because their fine-motor coordination improves but because they write more slowly, less impulsively. Ideally, a child with ADHD is placed in a structured classroom, where he knows what is expected of him and where the teacher (and school) are flexible about working with the child's strengths and weaknesses. The child often requires auditory or visual aids and other organizational supports. Close and frequent communication with parentsat least weeklyis crucial to maintain satisfactory progress. Two mechanisms are in place for providing extra educational help to children with ADHD: The Individuals with Disabilities Education Act (IDEA) provides access to special education for children with disability.11 The formal educational review team at the school must determine whether the child qualifies for services under IDEA, under any one of three categories: specific learning disability, emotional disturbance, or "other health impaired." A special Individual Educational Plan is drawn up for the child that provides accommodations for three years and is renewable upon repeat assessment. The "other health-impaired" category is often applied to children who have a chronic medical problem, such as diabetes, asthma, and ADHD. Section 504 of the Rehabilitation Act of 1973 is part of civil rights legislation to prevent discrimination against anyone with a disability.12 Under federal law, ADHD is an educational disability. Section 504 often is used to provide services for children with ADHD who do not qualify for IDEA access to special education. Again, the child must be evaluated to determine if the ADHD significantly limits his ability to learn. Common accommodations under this law are preferential seating, extra time for tests, modified homework assignments, monitoring systems, and written assignment sheets. Parents need to apply for accommodations under either IDEA or Section 504. An individual determination is made as to which plan is most appropriate. In general, children with greater academic deficiencies do better under IDEA, which provides for greater intervention and remediation. Now, let's examine the only two evidence-based treatments for ADHD: behavioral therapy and medication. Behavioral therapy. An effective program of behavioral therapy for ADHD has one or more of the following three components13: Parent training. Parents need to be taught simple techniques that many of them have read about and already put into practice, like giving clear and concise commands and using praise, time-outs, reward and consequence systems, and token economies. (In a token economy, the child earns rewards and privileges for desired behaviors and loses these rewards for undesirable behavior.) Why do parents find practicing these techniques so difficult? Because children with ADHD are more challenging and more oppositional than other children. The genetic basis of ADHD compounds this difficulty: Many parents have persistent ADHD themselves and struggle with their own problems, including lack of organization and follow-through. The best way to train a parent is with a referralto a counselor for one-on-one training or to parent classes. Classes are more cost-effective, and have the added benefit of providing an educational and support system to the parents. Daily report card.This report card focuses on classroom behaviors and goals for changing behaviors as needed. The teacher completes the report card each day. Parents review the report cards daily and give weekly rewards for accomplishing set goals. Despite the seeming simplicity of this approach, its validity is well established. Summer camp programs. These programs are conducted in natural settings and last six to eight hours a day for several weeks. Children spend time in academics and recreation. A high staff:child ratio ensures immediate and appropriate behavioral intervention. Such programs are more expensive than regular camp programs, however, and, nationwide, only a few are in operation. Regardless of its type, the emphasis of behavioral therapy is not on ADHD symptoms per se but rather on the functional impairments that ADHD causes in the child's daily life, such as not completing assignments and not complying with parents' requests. Last, despite widespread use, neither cognitive behavior therapy nor "play therapy" has been shown to be a scientifically based treatment for ADHD. Social skills training, such as anger management classes run by the school counselor, also has been found to be ineffective because such training lacks intensity or does not occur in a natural environment. Medication. The fact that medications for ADHD alleviate symptoms only when they are taken underscores the importance of behavioral therapy in the management of ADHD. Keep in mind, too, that symptoms return immediately when medication is discontinued and that many children, particularly adolescents, stop taking their medication after a few months. The large, landmark Multimodal Treatment Study of Children with ADHD, or MTA, sponsored by the federal government and with its findings published in 1999,9 offers insight into the relative benefits of various types of ADHD therapy. In this multisite study, 579 subjects, 7 to 9 years old, with the combined type of ADHD (all three core symptoms present) were assigned to one of four treatment groups: medication only; behavior therapy only; combined behavior and medication therapy; and community-based care (control group). When results were tabulated after 14 months of the study, several conclusions could be drawn: Medication was the most effective single treatment. Adding behavioral therapy to medication did not improve therapeutic effectiveness to a statistically significant extent, but it did evoke greater parental satisfaction, appeared to work better if comorbid anxiety disorder and oppositional behavior were present, and, possibly, led to use of less medication. Results seen in the research groups, compared with results in the community control group, indicated that a regimen in which medication is given over 12 hours of the day is superior for combined-type ADHD compared to a regimen in which medication is given over eight hours of the day. The nitty-gritty of pharmacotherapy Stimulant medications for ADHD are divided into the two major types: amphetamines and methylphenidate.14 Both are available in four-, eight-, and 12-hour preparations. Deciding on an agent with which to initiate therapy should be individualizedtaking into account age, desired duration of effect, and availability (depending on the pharmacy or health insurance plan, if any). When prescribing any of these medications, a few general principles usually apply: Because, unit for unit, amphetamines are twice as strong as methylphenidate, the latter is preferable for initial treatment (to fine-tune the dosage and to avoid side effects). Although methylphenidate and amphetamine are each about 70% effective in alleviating the symptoms of ADHD, collective effectiveness reaches, or exceeds, 90%. Try both types in succession before giving up on psychostimulant therapy. Start at the lowest-level dosage available and titrate up every five to seven days, using parent and teacher feedback, either verbal or (preferably) on a rating scale. (The Vanderbilt follow-up scale, for example, measures both ADHD traits and impairment/performance.) To maximize response, continue titration (in the absence of significant side effects) to at least one dosage level higher when a patient first responds positively to medication. Almost all children who have ADHDparticularly those who have the combined typedo best on therapy of 12 hours' duration. Ideally, a single morning dose of a 12- hour preparation can be used. Do not discontinue treatment on weekends or vacations. Exceptions may be made for special circumstances, such as poor weight gain, when a lower dosage may be appropriate. Utilize monthly telephone calls for medication refills to reaffirm that the patient's progress in academics and behavior is satisfactory, and that side effects have not developed or are minimal. Monitor the patient for height, weight, and blood pressure at least every three months if younger than 12 years or every 6 months if older than 12 years. Monitor more often in extenuating circumstances (e.g., poor weight gain). Treat or minimize side effects using the guidelines in Table 1 (American Academy of Pediatrics, National Initiative for Children?s Healthcare Quality. Caring for Children with ADHD: A Resource Toolkit for Clinicians. Elk Grove Village, IL, American Academy of Pediatrics, 2002) in the print issue.14 New to the medicine cabinet Atomoxetine is the first medication to be approved by the US Food and Drug Administration to treat ADHD in more than 30 years. The drug is a selective norepinephrine reuptake inhibitor, not a psychostimulant. One advantage of atomoxetine is that it is not a Schedule II controlled substance. It also does not have the potential for abuse15 (see Table 2). TABLE 2 Nonstimulant medication management information Data demonstrate that a dose of atomoxetine is effective for at least 18 hours. On the minus side, maximal response to atomoxetine may not be achieved for two to four weeks after the drug is begun. (For this reason, it is important when switching from a stimulant medication to atomoxetine to continue the stimulant for at least four weeks after starting atomoxetine before tapering and then discontinuing the drug.) Side effects include stomachache, anorexia, weight loss, and drowsiness. Atomoxetine does not potentiate tics. Off-label medications and other treatments Minimal research evidence shows that several classes of medication that do not have an FDA-approved indication for ADHD are sometimes effective in reducing the symptoms of ADHD. When other treatments fail, these agents may have some limited usefulness. Tricyclic antidepressants, such as imipramine and desipramine, should be used carefully because they may be cardiotoxic. Baseline and serial cardiac monitoring during titration is required. Think twice about prescribing one of these agents for a patient who lives with a toddler, for whom accidental ingestion may be fatal. Alpha agonists, such as clonidine or guanfacine, occasionally are a useful option in an ADHD-associated tic disorder or Tourette syndrome if a stimulant makes such symptoms worse (although a trial of a different type of stimulant is also an option). Some observers are concerned about sudden death that has occurred after patients took an agonist and methylphenidate. The connection has not been definitively proved. Bupropion, an atypical antidepressant, has a weak effect on the symptoms of ADHD. The drug may exacerbate tics. It is contraindicated in seizure disorders and eating disorders. The sustained release form is safest; dosage should not exceed 400 mg/day. Unproven or disproven treatments for ADHD are numerous. Many controversial therapies have been suggested for which there are no evidence-based data to confirm effectiveness.15 These include special elimination diets (free of preservatives and additives), megavitamins, food supplements, herbal supplements, special lenses, eye muscle training, blue-green algae, electroencephalogram biofeedback, and sensory integration therapy. Tools from the AAP In 2001, the American Academy of Pediatrics (AAP) published evidence-based guidelines for treating children with ADHD (see the Key Points box).6 These guidelines, which followed the release the preceding year of diagnostic guidelines for ADHD, emphasize the need to view the disorder as a chronic condition. This is entirely appropriate: In most children, ADHD persists through adolescence into adulthood. Care of a chronic illness requires most practicing pediatricians to adopt a alternate mindset; after all, we spend 85% of our clinical hours in well-child care and treating acute illnesses. ADHD often requiresas other chronic illnesses doa team approach, the team comprising child, parents, physician, teacher, counselor, and various specialists. Chronic care calls for setting target goals and developing a management plan to achieve them. A well-documented follow-up plan must be in place. If target goals are not achieved, the clinician must go back to the drawing board to ascertain the reason for failure: Perhaps the diagnosis is wrong. Possibly, the patient or his family is not complying with the treatment program. Or maybe a coexisting condition, undiagnosed or untreated, has confounded the situation. Because any one of these scenarios is plausibleindeed, likelyin the management of a case of ADHD, vigilance is required. The AAP Toolkit is another useful tool to aid the primary pediatrician in assessing and treating ADHD. Developed jointly by the AAP and the National Initiative for Children's Healthcare Quality (NICHQ) by a collaborative of pediatric practice teams and ADHD consultants, the toolkit offers assessment tools, guidelines, management plans, report cards, and patient handouts, among other aids. It can be downloaded at the NICHQ Web site ( www.nichq.org ) or purchased from the AAP (at www.aap.org ). Pediatricians also have available to them, through the AAP, a new on-line educational module, "Managing Your Patients With ADHD," that is accessible through the Web site of the academy's Education in Quality Improvement for Pediatric Practice initiative ( www.eqipp.org ). This program provides a systematic approach to diagnosis and management of ADHD, and offers physicians the opportunity to earn 20 hours of American Medical Association Physician's Recognition Award Category I credit. In addition, by providing a quality improvement exercise in the physician's chart, the program will eventually fulfill the practice performance requirements of the American Board of Pediatrics' maintenance-of-certification process. We've come a long way Because ADHD is so complex a condition, it has taken many years for medical science to develop an understanding of how best to manage it. It is fortunate for our patients that we now have access to a variety of effective medications and to a wealth of information about useful behavioral interventions and educational resourcesfor clinicians, for patients, and for their families. Note Previously, Dr. Gephart served as medical director of an ADHD clinic that, over a 14-year period, offered weekly parents' training sessions. Readers are invited to contact him at 425-827-4600 for information about this program and its publications. REFERENCES 1. Still GF: Lectures to the Royal College of Physicians. "Some abnormal psychical conditions in children." Lancet 1902:1008 2. Bradley C: The behavior of children receiving Benzedrine. Am J Psychiatry 1937;94:577 3. Eisenberg L: The management of the hyperkinetic child. Dev Med Child Neurol 1966;8:593 4. Laufer MW, Denhoff E: Hyperactive behavior syndrome in children. J Pediatr 1957;50:463 5. Greenhill LL, Pliszka S, Dulcan MK, et al: Practice parameter for the use of stimulant medications in the treatment of children, adolescents, and adults. J Am Acad Child Adolesc Psychiatry 2002;41(2 suppl):26S 6. American Academy of Pediatrics: Clinical practice guideline: Treatment of the school-aged child with attention-deficit/hyperactivity disorder. Pediatrics. 2001;108:1033 7. Spencer T, Biederman J, Wilens T, et al: Pharmacotherapy of attention-deficit hyperactivity disorder across the life cycle. J Am Acad Child Adolesc Psychiatry 1996; 35:409 8. Swanson J: Effect of stimulant medication on children with attention deficit disorder: "A review of reviews." Exceptional Child 1993;60:154 9. The MTA Cooperative Group: A 14-month randomized clinical trial of treatment strategies for attention-deficit/ hyperactivity disorder. Arch Gen Psychiatry 1999;56:1073 10. Conners CK, Epstein JN, March JS, et al: Multimodal treatment of ADHD in the MTA: An alternative outcome analysis. J Am Acad Child Adolesc Psychiatry 2001;40:159 11. Individuals with Disabilities Education Act (IDEA) 1997. U.S. Code at Vol. 20, beginning at Section 1401 12. Rehabilitation Act of 1973. Section 504. U.S. Code at Vol. 20, beginning at Section 706 13. Pelham WE Jr, Fabiano GA: Behavior modification (in ADHD). Child Adolesc Psychiatr Clin N Am 2000;9:671 14. American Academy of Pediatrics: Caring for children with ADHD: A resource toolkit for clinicians. http://www.nichq.org/resources/toolkit/13StimulantMedicationManage.pdf 15. Assessing Complementary and/or Controversial Interventions-CHADD Fact Sheet #6. http://www.chadd.org/fs/fs6.htm DR. GEPHART is clinical professor of pediatrics, University of Washington School of Medicine, Seattle, and consultant on ADHD to Pediatric Associates, Bellevue, Wash. He is a consultant for Eli Lilly & Company and McNeil Consumer and Specialty Products and serves on the speakers' bureau for Eli Lilly and McNeil and for Novartis Pharmaceuticals Corp. Resources about ADHD Books For parents Taking Charge of ADHD, by Russell A. Barkley, PhD. The Guilford Press, New York/London. (Revised edition 2000) Teenagers with ADHDA Parents' Guide, by Chris A. Zeigler Dendy. Woodbine House, Bethesda, Md., 1995 For parents and educators The ADHD Book of Lists, by Sandra F. Rief. Jossey-Bass, San Francisco, 2003 For adults with ADHD Driven to Distraction, by E. M. Hallowell and J.J. Ratey. New York, Random House, 1994 For clinicians ADHD: A Complete and Authoritative Guide, by the American Academy of Pediatrics, edited by Michael Reiff, 2003 Web sites Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD) www.chadd.org Attention Deficit Disorder Association (ADDA) www.add.org San Diego ADHD Web Page www.sandiegoadhd.com Learning Disabilities Association of America www.ldanatl.org American Academy of Pediatrics www.aap.org AAP's Education in Quality Improvement in Pediatric Practice www.eqipp.org National Initiative for Children's Healthcare Quality (NICHQ) www.nichq.org Key points from the AAP's guidelines for treating ADHD* Primary care clinicians should establish a treatment program that recognizes ADHD as a chronic condition. The treating clinician, the parents, and the child, in collaboration with school personnel, should specify appropriate target outcomes to guide management. The clinician should recommend stimulant medication and/or behavioral therapy as appropriate to improve target outcomes in children with ADHD. When the selected management for a child with ADHD has not met target outcomes, clinicians should evaluate the original diagnosis, use of all appropriate treatments, adherence to the treatment plan, and presence of coexisting conditions. The clinician should periodically provide a systematic follow-up for the child with ADHD. Monitoring should be directed to target outcomes and adverse effects by obtaining specific information from parents, teachers, and the child. *For children age 6 to 12 years Source: American Academy of Pediatrics6 Harlan Gephart. Where we are, and how well we can succeed, at treating ADHD. Contemporary Pediatrics December 2003;20:77.