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Facts
of Life
Facts of Life:
Issue Briefings for Health Reporters
Vol. 10, No. 6
June 2005
ADHD: The Changing Face
of ADHD Treatment
The Issue
The Facts
Expanding ADHD Treatments
Expert Sources
References
The
Issue:
Attention-deficit/hyperactivity
disorder is the most common psychiatric condition among children in the United
States.
Differing estimates suggest that 3 percent to 10 percent of school-age children
have ADHD, a disorder characterized by consistent inattention, hyperactivity
or impulsiveness. Diagnosing ADHD is difficult, since most people, and particularly
children, are impulsive or inattentive some of the time. However, a patient
with ADHD demonstrates these behaviors “to a degree that is inappropriate
to a person’s age,” according to guidelines from the National Institute
of Mental Health.1
Not Just for
(School) Kids Anymore
Although most cases of ADHD are diagnosed in children when they enter school
for the first time, a growing number of children younger than 6 years old are
being diagnosed. ADHD diagnoses among adults are also on the rise. ADHD expert
Russell Barkley, Ph.D., of the Medical University of South Carolina, estimates
that about 5 percent of American adults suffer from the condition. Some of
these people may have had ADHD since childhood: Studies suggest that between
30 percent and 70 percent of children with ADHD continue to show symptoms of
the disease as adults.2
Collateral Damage
Researchers have discovered that the disorder often coexists with other conditions
like depression and anxiety. Recent studies show that teenagers and adults
with ADHD are more likely to develop harmful health behaviors such as drug
abuse and reckless driving. These comorbid conditions increase the personal
and public health costs of ADHD.
The
Facts:
- A review of ADHD
studies concludes that 80 percent of ADHD cases have a genetic cause.3
- Mothers who smoke
during pregnancy have a higher risk of giving birth to a child with ADHD,
according to a 2003 systematic review.4
- According to a systematic
review of attention-deficit/hyperactivity disorder studies, 70 percent
of children taking stimulant medications have short-term – less than
two years – improvements in ADHD symptoms.5
- The stimulant methylphenidate
(Ritalin) and amphetamines are the ADHD medications backed by the strongest
evidence for their effectiveness, according to a
recent review of medications for the disorder.6
- A 2004 review estimates
that many as 30 percent of children with ADHD do not respond to stimulant
medications or are unable to tolerate side effects from those treatments.7
- Preschool children
(ages 3 to 6) with ADHD experience a greater
variety of responses and side effects to stimulant medication than older
children, according to a 2002 review.8
- A 2002 systematic
review of ADHD studies concludes that there is “little evidence” that
stimulant medication improves academic performance in children with ADHD.9
- A 2004 review of ADHD
clinical studies suggests the disorder is often associated with cigarette
smoking and substance abuse in children and adults.10
- Unmedicated children
with ADHD experience less REM sleep and more daytime sleepiness compared
to children without ADHD, according to a systematic review of sleep studies.11
- A number of studies
suggest drivers with ADHD have increased risks of speeding tickets and
repeated and severe car crashes compared to those without the disorder.12
- More than one-third
of children with ADHD also have symptoms consistent with an anxiety disorder,
according to a 1999 diagnosis report commissioned by the Agency for Healthcare
Research and Quality.13
- Direct medical costs
for children with ADHD may be twice as high as those for children without
the disorder, according to recent estimates.14
Expanding
ADHD Treatments
According
to several systematic reviews, good evidence suggests that stimulant medications
such as Ritalin or amphetamines can reduce the symptoms of ADHD in children.
The evidence is so persuasive that the American Academy of Pediatrics includes
the use of stimulants as one of its top clinical guideline recommendations
for treating the disorder.15 This strong recommendation coexists, however,
alongside a number of other options for treatment and questions about how
ADHD therapies might be tailored to specific patient groups.
Behavior
therapy is an alternative treatment pursued by the significant number of
patients who do not respond to stimulants or are reluctant to take the drugs.
Many patients also supplement their drug treatment with some kind of behavior
therapy. The evidence for behavior therapy’s effectiveness is much weaker
than the evidence for stimulant medications, however, and “almost all
studies comparing behavior therapy with stimulants alone indicate a much stronger
effect from stimulants than
from behavior therapy,” the AAP guidelines conclude.
Behavior
therapy is not without some
supporting data, although few high quality studies of the treatment exist,
ccording
to University of Oxford researcher Gretchen Bjornstad, Ph.D., and
colleagues. Their 2005 Cochrane Collaboration systematic review suggests,
for instance, that a behavior-oriented family therapy program can be more
effective
than a medication placebo for treating ADHD, but the conclusion is based
on only one study.16
The choice
to include behavior therapy in a child’s ADHD treatment plan “is
not a trivial one,” says University of Pittsburgh researcher Heidi Feldman,
Ph.D. M.D., a member of the AAP committee that drew up the 2001 ADHD guidelines.
“
Parents and teachers are more satisfied with treatment when behavior is added,
and parents’ satisfaction is one component of a child’s continued
adherence to the plan,” she explains.
Research shows that behavior therapy can be “particularly good for certain
subgroups within ADHD patients, for example, children who have poor relationships
with parents. Those who have lots of opposition and aggression in the family
often benefit” from behavior treatments, Feldman says.
ADHD is
a unique chronic disorder that might also be treated in some cases with educational
therapy, although very little information exists on such treatment,
according to Feldman.
“
We would like to know what kind of educational programs could be useful to
kids with ADHD, if there is a class size or teaching method appropriate for
ADHD,” Feldman says. “Does project-based learning serve children
with ADHD better? Is computer-based learning better because it engages their
limited attention?”
The agenda
of a July 2005 AAP conference addressed another question about ADHD treatments:
How long do they last? Feldman says researchers “feel a little
bit in the dark about what kinds of treatments make an impact on children in
the long run. Most studies last a year or so, but we want to know if there
are things we do that make a difference in five years or ten years.”
Expert
Sources:
References
1. National Institute
of Mental Health, National Institutes of Health (2003) Attention Deficit
Hyperactivity Disorder; last accessed 05/11/05 at http://www.nimh.nih.gov/publicat/NIMHadhdpub.pdf.
2. L.B. Silver LB. (2000)
Attention-deficit hyperactivity disorder in adult life. Child and Adolescent
Psychiatric Clinics
of North America, 3: 411–523.
3. K.K. Voeller (2004)
Attention-deficit hyperactivity disorder (ADHD). Journal of Child Neurology,
19, 798–814.
4. K.M. Linnet et al.
(2003) Maternal lifestyle factors in pregnancy risk of attention deficit
hyperactivity disorder
and associated behaviors: review
of the current evidence. American Journal of Psychiatry, 160, 1028–1040.
5. L.A. Johnson et al.
(2005) Clinical inquiries. What is the most effective treatment for ADHD
in children? Journal
of Family Practice, 54, 166–168.
6. M. Olfson (2004) New
options in the pharmacological management of attention-deficit/hyperactivity
disorder.
American Journal of Managed Care, 10:S117–124.
7. K.C. Daley (2004) Update
on attention-deficit/hyperactivity disorder. Current Opinion in Pediatrics,
16, 217–226.
8. D.F. Connor (2002)
Preschool attention deficit hyperactivity disorder: a review of prevalence,
diagnosis,
neurobiology, and stimulant treatment. Journal
of Developmental and Behavioral Pediatrics, 23, S1–9.
9. R. Schachar et al. (2002) Attention-deficit hyperactivity disorder: critical
appraisal of extended treatment studies. Canadian Journal of Psychiatry, 47,
337-348.
10. T.E. Wilens and W.Dodson
(2004) A clinical perspective of attention-deficit/hyperactivity disorder
into adulthood.
Journal of Clinical Psychiatry, 65, 1301–1313.
11. M. Cohen-Zion and
S. Ancoli-Israel (2004) Sleep in children with attention-deficit hyperactivity
disorder (ADHD):
a review of naturalistic and stimulant intervention
studies. Sleep Medicine Reviews, 8, 379–402.
12. R.A. Barkley (2004)
Driving impairments in teens and adults with attention-deficit/hyperactivity
disorder.
Psychiatric Clinics of North America, 27, 233–260.
13. Agency for Health
Care Policy and Research (1999) Diagnosis of Attention-Deficit/Hyperactivity
Disorder.
Summary, Technical Review: Number 3, last accessed 05/11/05 at http://www.ahrq.gov/clinic/epcsums/adhdsutr.htm.
14. C.L. Leibson and K.H.
Long (2003) Economic implications of attention-deficit hyperactivity disorder
for healthcare
systems. Pharmacoeconomics, 21, 1239–1262.
15. American Academy of
Pediatrics (Subcommittee on Attention-Deficit/Hyperactivity Disorder and
Committee on
Quality Improvement) (2001) Clinical practice guideline:
Treatment of the school-aged child with attention-deficit/hyperactivity disorder.
Pediatrics, 108, 1033–1044.
16. G. Bjornstad and P.
Montgomery (2005) Family therapy for attention-deficit disorder or attention
deficit/hyperactivity disorder in children and adolescents
(Review) The Cochrane Database of Systematic Reviews, Issue 2
The
Center for the Advancement of Health is an independent nonprofit organization
that promotes greater recognition of how psychological, social, behavioral,
economic and environmental factors influence health and illness. The Center
advocates the highest quality research and communicates it to the medical
community and the public. The fundamental aim of the Center is to translate
into policy and practice the growing body of evidence that can lead to the
improvement and maintenance of the health of individuals and the public.
The Center was founded by the John D. and Catherine T. MacArthur Foundation
and the Nathan Cummings Foundation, which continue to provide core funding.
Funding for this series was provided by the Robert Wood Johnson Foundation.
For Information Contact:
Lisa Esposito
Editor, Health Behavior News Service
Center for the Advancement of Health
2000 Florida Ave., NW, Suite 210
Washington, DC 20009
p. 202.387.2829 / f. 202.387-2857
press@cfah.org
http://www.cfah.org
© Copyright 2005, Center
for the Advancement of Health
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