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New Treatment Guidelines for ADHD from
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In the
October 2001 issue of Pediatrics, the 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. The
discussion of each recommendation represents my synthesis of how each
recommendation was discussed along with ideas I have incorporated from other
sources. 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 overtime. 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: I think 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 those 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. In my opinion,
information on these aspects of functioning should be obtained at least
monthly. And, it is really not an
onerous task to obtain such feedback even more regularly from a child’s
teacher. I have developed a simple
monitoring system for ADHD that is available for free within the
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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