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In the October 2001
issue of Pediatrics, the American
Academy of Pediatrics
(AAP) published their evidence-based recommendations for the treatment of children
diagnosed with ADHD. The committee
responsible for preparing these guidelines included general pediatricians,
child psychiatrists, developmental pediatricians, family physicians, child
psychologists, and child neurologists.
The committee devoted three years to reviewing the published
literature on the treatment of children with ADHD. The resulting treatment
guidelines are based on the best scientific evidence currently available.
The
AAP guidelines are an extremely important resource for parents and
practitioners.. Knowledge of these
guidelines provides a basis for evaluating how the treatment being received
by one's own child or the children one works with professionally compares
to what has been recommended by an expert panel relying on state-of-the-art
scientific evidence. The
recommendations listed below are taken directly from the AAP document.
Recommendation
1:
Primary care clinicians should establish a management program that recognizes
ADHD as a chronic condition.
ADHD
is a chronic condition with no known cure and many children with ADHD will
manifest symptoms of the disorder into adolescence and beyond. Effective
treatment thus requires that a long-term management plan. The goal of this
plan is to minimize the adverse impact of ADHD symptoms over the course of a
child's development.
The
AAP guidelines emphasize that educating parents and children about ADHD is
critical in developing an effective management program. Parents and children should be informed about
the ways in which ADHD can affect learning, behavior, self-esteem, social
skills, and family functioning. Initially, this information helps to
demystify the diagnosis. It also
increases the likelihood that parents and children will participate in the
development of a comprehensive treatment plan that can be sustained over
time.
This
patient education process is ongoing: families should be provided with
important new information on ADHD as it becomes available. Clinicians should
direct families to resources that provide families with ongoing current
information (e.g. CHADD, http://www.chadd.org) and the opportunity to develop
supportive relationships with other families.
The
importance of educating parents and children about ADHD cannot be over-emphasized. Providing effective treatment/management
for a child with ADHD can be an extremely difficult process that must be
sustained over many years. When
families lack a solid understanding of how ADHD can affect children's
development, sustaining the efforts required to effectively manage a child's symptoms over an extended time can be
even more difficult.
It
is noteworthy that this guideline explicitly states that educating children
about ADHD is an integral part of the treatment/management process. Children
should be provided with an age-appropriate explanation of the condition and
how it may affect them in school, at home, and with peers. They should be
given the opportunity to ask questions about their condition. These questions
may need to be addressed on multiple occasions, and the nature of their
questions may change over time. A
child cannot be expected to be a cooperative partner in his/her treatment
without a clear understanding of what he/she is being treated for and why
treatment is necessary.
Recommendation
2:
The treating clinician, the parents, and the child, in collaboration with
school personnel, should specify appropriate target outcomes to guide
management.
This
recommendation emphasizes that effective management of ADHD requires an ongoing
collaborative effort that includes parents, the child, the school, and the
health care provider. This
collaborative effort should be focused on maximizing the child's functioning
in key social, academic, and behavioral areas, rather than on simply reducing
the levels of core ADHD symptoms. For
example, desired results would include:
*
improving the child's relationships with parents, siblings, teachers, and
peers;
*
decreasing disruptive behaviors;
*
improving academic performance;
*
enhancing self-esteem;
*
enhancing safety in the community.
Treatment
should begin with a clearly defined set of goals for the key areas in which a
child is struggling. These goals are
based on input from children, parents, and school personnel. (Once again, the value of including
children as collaborative partners in the development of a treatment plan is
emphasized.) The treatment goals
should be clearly specified (e.g. "John will complete his assigned work
on time."), manageable in number (e.g. 3-6 key treatment targets), and
realistic to attain. A plan needs to be put into place for determining how
success towards attaining each goal will be monitored and measured. Without such a plan, it will be difficult
to accurately evaluate the success of treatments that are implemented.
The
recommendation that treatment focus on functional improvement in key areas
(rather than on simply reducing/eliminating core ADHD symptoms) is
important. Parents and clinicians
should recognize that symptomatic reduction and functional improvement do not
always go hand-in-hand. For example, some children can show clear reductions
in inattention and/or hyperactivity but continue to struggle with schoolwork,
peer relations, etc. By focusing on functional improvement rather than simple
symptom reduction, parents and providers will be better able to identify such
situations and make appropriate adjustments/modifications to a child's
treatment.
Recommendation
3:
The clinician should recommend stimulant medication and/or behavior therapy
as appropriate, to improve target outcomes in children with ADHD.
What
treatment methods should be used to achieve the target outcomes developed as
recommended above? The AAP guidelines
recommend stimulant medication treatment and/or behavior therapy. The fact that these are the only 2
treatment options recommended does not mean that alternative treatments
do not work. It does indicate,
however, that these were the only treatments for which the committee felt sufficient
scientific evidence exists to justify their routine recommendation.
Beyond
this generic recommendation, the guidelines contain important information
about the use of each treatment. It is
noted that for most children "stimulant medication is highly effective
in the management of the core symptoms of ADHD." Research indicates that the most powerful
effects are found on measures of observable social and classroom behaviors
and on core symptoms of inattention, hyperactivity, and impulsivity. The effects on academic achievement are
more modest.
Although
most studies examining the efficacy of stimulant medication have been
short-term studies, recently published results from the MTA study indicated
that school-aged children with ADHD showed a marked reduction in core ADHD
symptoms over a 14-month period.
Despite these important gains, the majority of children treated with
stimulant medication do not demonstrate fully normalized behavior, and many
continue to show residual difficulties that need to be addressed via other
means.
Other
important aspects of medication treatment noted in the guidelines included
the following:
*
The longer term effects of stimulant medication treatment remain unclear and
the data required to evaluate long-term impact are not currently available;
*
There is currently no basis for recommending one brand/type of stimulant over
another and each stimulant improves core symptoms equally; (Note: The use of
Pemoline/Cylert is not recommended because of potential complications with
liver functioning);
*
The optimum stimulant dosages for a child are not weight dependent and it is
not possible to predict in advance what the best dose -- or most effective
stimulant -- will be for an individual child.
Clinicians should begin
with a low dose and gradually increase it across the full range of
recommended dosages to determine the best fit for each child.
(Note: The key point here is that the first dose
to which a child shows some response may not be the best dose to improve
function. It is only by testing a
child on a full range of doses and obtaining systematic feedback from parents
and teachers about the child's functioning on each dose that the best
recommended starting dosage for treatment can be determined.)
*
Children may respond favorably to one stimulant, but not another. For this
reason, physicians should not switch to a non-stimulant medication for
treating ADHD until a child has been tested on at least 2-3 different stimulants
across a full range of doses, without showing a significantly positive
response.
*
Available evidence indicates that stimulant medications are safe and well
tolerated by most children. Most side
effects occur early in treatment, are short-lived, and can often be
successfully managed through dosage adjustment or a change in
medication. No adverse effects of
long-term use of stimulant medication are currently known, although the need
for long-term safety studies is well documented.
*
The only medications other than stimulants for which efficacy in treating
ADHD in children has been demonstrated are tricyclic antidepressants,
bupropion, and clonidine. As noted
above, these should only be considered
after a child has not responded to a careful trial of 2-3 different
stimulants.
Behavior Therapy
Behavior
therapy is the other treatment specifically recommended for school-aged
children with ADHD. Behavior therapy
is usually implemented by training parents and teachers to consistently
reward the child for demonstrating desired behavior and providing negative
consequences for failure to meet behavioral goals. Several different techniques and strategies
(e.g. behavioral parent training, classroom management) can be utilized, and
in those with demonstrated efficacy, the focus is on structuring a child's
environment to provide consistent consequences for desired and undesired
behaviors rather than trying to teach the child new behavioral and/or
cognitive skills. These skills
training approaches although intuitively appealing -- have not yet been shown
to be clearly effective for treating the core symptoms of ADHD.
(Note:
It is important to emphasize that the above recommendation does not
necessarily mean there is no place for skills training in the treatment of
some children with ADHD. For example, some
children with ADHD may lack the social and problem-solving skills required to
establish and maintain good peer relationships. When these skills are poorly
developed, skill-building approaches can be helpful. The point to keep in mind, however, is that
skills training approaches are unlikely to help with core ADHD symptoms. And, effectively treating core symptoms via
medication and/or behavior therapy may obviate the need for skills training
approaches. For example, this would be the case for a child who has the
skills to interact
effectively with peers, but who is unable to use these skills consistently
without medication treatment because he/she is too impulsive. When a child
continues to display skill-related deficits even after core ADHD symptoms are
being effectively managed, these adjunctive skill building therapeutic
approaches should be considered.)
The
AAP guidelines note that, although positive effects for well-conducted
behavior therapy have been clearly demonstrated, there are important limitations
associated with this treatment. First,
almost all studies comparing behavior therapy with stimulants indicate a much
stronger effect from stimulants on the core symptoms of ADHD. Second, as with stimulant medication
treatment, behavior therapy often does not bring an ADHD child's behavior
into the normal range. Finally,
behavior therapy does not generally yield positive changes that persist
beyond the time when it is being implemented.
Parents using this approach thus need to be prepared to sustain the
treatment over the entire course of their child's development. This necessity
is consistent with the notion of ADHD as a chronic condition rather than
something that can be "cured" by treatment.
Recent
data from the MTA study indicate that the combination of careful medication
treatment and behavior therapy provides some significant benefits relative to
medication treatment alone. For
example, on an overall measure of treatment outcome, children receiving combined
treatment showed greater improvement than children treated with medication
alone. In addition, children receiving
combined treatment required a significantly lower dose of medication over the
14-month study. Finally, parents and
teachers of children receiving combined treatment were significantly more
satisfied with the treatment plan.
Recommendation
4 -
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.
This
recommendation is based on the premise that well-conducted medication and/or
behavior therapy should yield clinically significant benefits for the vast
majority of children with ADHD. When
such benefits fail to occur, this guideline identifies several prominent
reasons that should be considered.
First,
the original diagnosis of ADHD may be incorrect and the basis upon which the
diagnosis was made should be reevaluated.
Unfortunately, prior research has shown that many children are
incorrectly diagnosed with ADHD and then treated inappropriately with
stimulant medication. (Note: An equally important problem is the probably
far greater number of children with ADHD who are never identified or treated.)
Second,
clinicians and parents should examine whether the goals being targeted can be
realistically accomplished or whether they have been set "too
high". Care must be taken to set
behavioral and academic goals that are within a child's reach.
Third,
the treatment plan should be reevaluated to determine whether it is
comprehensive enough to address a child's difficulties. For example, although medication and
behavioral intervention have both been shown to be effective treatments for
ADHD, limiting a child's treatment to one of these options alone may not be
adequate in many instances.
Fourth,
adherence to the treatment plan should be looked at carefully. If a child
fails to consistently receive medication as prescribed, such treatment is not
likely to provide meaningful benefits.
Behavioral interventions are also unlikely to yield any substantial
benefits unless they are faithfully implemented over a sustained time
period. If a well-designed treatment
plan is not providing desired results because it is not being adhered to,
reasons for non-adherence to the treatment plan need to be identified and
addressed.
Abandoning
such a plan before it has been given a fair test would not be advisable.
Finally,
careful consideration needs to be given to whether co-existing conditions are
present that may complicate the treatment of ADHD. Children with ADHD are at
increased risk for a variety of other disorders, including learning
disabilities, mood and anxiety disorders, oppositional defiant disorder (ODD),
and conduct disorder (CD). When one or
more of these disorders co-occur with ADHD, interventions in addition to
standard ADHD treatments are often required.
Although a thorough evaluation for ADHD should
include assessment for co-occurring conditions so that treatment plans can be
developed accordingly, this may not have occurred. Thus, when ADHD treatment is not yielding
desired results, the possibility that an important co-occurring condition has
been missed should be carefully considered.
Recommendation
5:
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.
The
importance of this recommendation cannot be overemphasized. A significant limitation in the treatment
received by many children with ADHD is the lack of adequate follow-up and
monitoring. When careful monitoring of
treatment success is lacking, an ineffective treatment regimen may continue
without the necessary adjustments or modifications being made.
In
the MTA study, an important treatment feature was that monthly follow-ups
were scheduled for children treated with medication. At these follow-ups, direct information on
the child's functioning was obtained from parents and teachers. Problems that may have emerged were thus
identified quickly and appropriate
modifications to the medication treatment were made.
It
is important to note that, even though an extremely rigorous procedure was
used in the MTA study to identify the optimum dose of medication for each
child, dosage adjustments over the next 13 months were common and some
children were even switched to new medications. For example, three months into the
maintenance period for children receiving medication in the MTA study, 56%
had already had their medication or dosage changed. The average amount of time to the first
dose change was between 4 and 5 months.
Across
the entire maintenance period, the average number of changes required for
each child was just over 2, but some children required as many as 10
medication adjustments. Of the total
medication changes made, 62% involved increasing the dosage of the current
medication, 31% involved decreasing dosage, and 7% involved changing types of
medication. These changes were
required in order to maintain adequate management of children's symptoms.
The
AAP guidelines state that the frequency of monitoring will depend on the
"...degree of dysfunction, complications, and adherence" and there
is no research that specifies the appropriate frequency of follow-up visits.
The guidelines state that once a child is stable, an office visit every 3-6 months
is necessary to allow for the assessment of learning and behavior. It is also
noted, however, that additional communication should occur at more frequent
visits to refill medication, and that parents should be asked about
functioning at home, school, and in interpersonal relationships. Any apparent
decrease in the child's functioning should be carefully evaluated to
determine whether treatment modifications should be implemented.
Providing
systematic monitoring for a child being treated for ADHD does not have to be
a difficult task. If a systematic
procedure for tracking how well treatment outcome targets are being met is
implemented, failure to consistently achieve target outcomes will be readily
apparent. For a school-aged child, a
reasonable set of parameters to monitor at school would include:
*
how well core ADHD symptoms are being managed;
*
the child's ability to follow classroom rules;
*
the quality of peer interactions;
*
general mood;
*
the quality of academic performance.
Information
on these aspects of functioning should be obtained at least monthly.
Summary and
Conclusions
The AAP treatment guidelines will hopefully
spur significant improvements in the quality of care received by children
with ADHD from primary care physicians.
Based on the best evidence currently available, they present a clear
set of principals that should be incorporated into each child's treatment. In summary, the elements of optimum
treatment should include:
1)
a management plan that is consistent with the chronic
nature of ADHD and which educates parents and children about the condition;
2)
a clear set of treatment goals that focus on functional
improvement and which are developed in collaboration with parents, children,
school personnel, and providers;
3)
the use of empirically based treatments including
stimulant medication and/or behavior therapy; and
4)
close monitoring of treatment outcomes and failures.
Because
research on the long-term impact of treatment that carefully adheres to these
treatment guidelines is not currently available, the ultimate impact of such
treatment on children with ADHD is not known.
The key to promoting the long-term success of a child with ADHD,
however, is to make each day as successful as possible for that child. It is through stringing together successful
days into successful weeks, successful weeks into successful months, and
successful months into successful years, that favorable long-term outcomes
will be achieved.
Based
on the current state of our knowledge, careful adherence to the AAP
guidelines is the best way to accomplish this, and one hopes that primary
care physicians will make the necessary adjustments in their practice to make
sure this occurs.
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