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Public
Health Issues in the Treatment of ADHD Workshop
June
15, 1999
Participants:
William Pelham,
Jr., Ph.D.,
State University of New York, Buffalo
Laurence L. Greenhill, M.D., New York State Psychiatric
Institute
By far the most
controversial, and at the same time, most important public health concern in
ADHD is the treatment of the disorder, especially among our nation’s
youth. The most common treatment is the psychopharmacological agent,
methylphenidate. Methylphenidate is a schedule II narcotic which is
regulated by the DEA as a controlled substance. It is a psychotrophic drug
with chemical properties, placing it in the amphetamine family of
stimulants. Due to the lack of research of the long-term efficacy (greater
than 24 months and in preschool populations) and safety of such treatment at
the population level, a public health perspective should be applied to the
treatment of ADHD. The lack of such research, coupled with an increase in
length of treatment during the formative growth years; a decrease in the age
of initiation into treatment; and the growing prevalence estimates are cause
for concern. As treatment options are considered, it is apparent that more
reliance is placed on pharmaceutical remedies than on psychological
interventions such as behavior modification, although the latter have been
shown to have beneficial effects. Apparent emphasis on pharmacological
intervention as first-line treatment exists in common practice despite a
lack of adequate evidence of long-term academic and functional improvements
using this intervention.
In an effort to delineate
the issues in the treatment of ADHD individuals as well as gaps in treatment
research, the Division of Birth Defects, Child Development, and Disability
and Health (proposed)/NCEH hosted a one-day meeting with two researchers
experienced in the study of ADHD treatments and the NCEH ADHD work group
which is comprised of DDB staff. Prior to the meeting Division of Birth
Defects, Child Development, and Disability and Health (proposed) had
identified and provided to all participants an outline of the specific
issues and questions related to the pharmacological and psychological
treatment of ADHD. The questions and discussion that ensued resulted in the
following points during this one-day meeting:
Please note that all
answers are the summarized sentiments of the participants invited to this
meeting and not those of the CDC. Statements herein are not, in any way, to
be interpreted as promissary for inclusion in any ADHD research agenda
setting nor are they ADHD policy statements by the Centers for Disease
Control and Prevention, National Center for Environmental Health. This
meeting was exploratory in nature and the results are provided here in an
attempt to share the most information with the public.
Q1.
What is the agreed upon standard of a reasonably reliable/valid ADHD
assessment that will identify a clinically meaningful disorder? (Consider
whether the standard is uniformly applied and what the commonalities and
differences among providers in diagnostic practice are.)
There is agreement among
professionals that there are reasonably valid/reliable ways of assessing
ADHD; however, common practice among disciplines in identifying ADHD varies
widely.
It was noted that there
is no evidence to date showing that a full psychological interview-based
assessment is markedly better at identifying ADHD than the use of rating
scales completed by multiple informants.
However, it was noted
that not only meeting symptom criteria but also displaying a level of
impairment should be the standard for reliably making the diagnosis in the
population and research efforts. Such impairment should occur in more than
one setting.
Although the diagnosis
can be consistently and reliably identified, there is a need for a
consistent standard for practitioners for case identification and prevention
of further impairment or comorbidity whenever possible.
Q2. How are
comorbidities diagnosed and addressed in terms of treatment? (Should
we be concerned if comorbidities present with ADHD are not identified or
treated? What are the risks in that scenario?)
This issue was not
specifically addressed, but it is understood that assessment should include
screening for comorbidity and treatment where appropriate.
Q3. Could you
comment on the difference between ADHD identified in epidemiologic studies
and ADHD identified by a clinician or psychiatrist? (What is
an ideal case ascertainment method in your opinion?)
Using the latest
technology, one gets something different epidemiologically from child
psychiatrists than from family practitioners and pediatricians. Whereas
doctors often stop asking questions before they have all the answers,
current epidemiologic instruments ask all the questions but are not able to
show whether the impairment is from LD, ADHD or another source. All the
questions need to be asked, however, and in this respect, an epidemiologic
model has the best chance of gathering the most data.
Q4. What are the key
issues surrounding the diagnosis of the disorder that we might address with
more research or policy guidance?
There are many reliable
scales for assessment, but they are often viewed differently by teachers and
doctors. CDC could establish a standard way to look at these scales, or a
best practices approach to them, for physicians and/or researchers.
CDC could set up practice
parameters, steps to take before treatment, algorithms for treatment, etc.
and, consequently, field test them to see if doctors follow them
effectively.
Q5. Long-term effects on
brain chemistry for chronic ADHD treated with stimulants–Issues in health
risks and benefits:
–What is the average
length of pharmacological treatment for children and (if applies) for
adults?
A 1996, study attributed
the increase in ADHD rates to an increase in the length of treatment. The
average treatment had been from six months to a year, and, occasionally, to
several years; however, ten years of treatment is not uncommon now for
children identified before puberty.
Currently, there are no
pharmacologic data on preschool children at all; therefore, the average
length of treatment among this population is not known. However, ADHD is a
chronic disorder and could potentially require treatment throughout life.
–Address what we know
about early initiation of psycho-stimulant use (ages 3-4).
Ritalin has been found to
be effective in young children, but also to produce higher rates of side
effects in this group. With school-age children, there is strong evidence of
short-term, dose-related side effects, but the evidence is not clear for
preschoolers.
The label on Ritalin
warns against prescribing it for children under six years of age, but, in
practice, it is increasingly being prescribed to younger children.
It was noted that Ritalin
works on dopamine receptors, which are still forming during the preschool
years. Not enough is known about how this treatment regimen affects
preschoolers’ brain development and what the risk for later illicit drug
use may be.
–Is there empirical
support for early identification and treatment providing increased benefits
or better outcomes?
In theory, if medication
is started earlier, there should be a better outcome due to short circuiting
negative peer interactions, but it is not known if the medication is safe.
No control studies have
been conducted to test specific therapies in the preschool years to monitor
for long-term benefits of early identification and treatment for ADHD and
common comorbidities.
Little research has been
done in this area, but some has looked at parent/child interactions and
found that they improved with early treatment.
Studies with small
samples and questionable validity have shown that children given short-term
drug therapy, without psychosocial treatment, quickly revert when the drugs
are removed.
–What are known or
suspected health risks associated with this treatment modality?
Slower growth and weight
gain are side effects of stimulants and can cause significant suppression of
appetite.
Difficulty sleeping is
also a side effect of the medication.
–Address
self-medication later in life with tobacco, drugs, other stimulants, and
alcohol–is this related to stimulant use in childhood?
Few data exist on later
licit/illicit drug use related to ADHD medication, but, so far, no one has
found an increase in later licit/illicit drug use in children who have been
medicated.
Some researchers have
shown earlier onset and heavier use of tobacco products among ADHD
individuals who have not been treated. Similarly, researchers have shown
delayed use of tobacco and experimentation with drugs in those medicated for
ADHD, but these data are still being analyzed and are from a clinic-based
sample. Good data on tobacco use are not available.
Q6. To what extent has
the efficacy of pharmacological treatments been shown and approximately, for
what proportion of treated cases does such treatment ameliorate the symptoms
of ADHD or improve long-term outcomes?
Pharmacological
treatments have clear effects on the expression of ADHD symptoms. Such
therapies are usually effective in reducing symptom expression for about 70%
of ADHD cases. However, pharmacological interventions may not contribute to
improved long-term outcomes. Without more research, especially longitudinal
research, it is difficult to say whether pharmacological interventions offer
substantial benefits above and beyond the reduction of symptomotology for
the drugs’ active period (e.g. regular preparations of methylphenidate
reduce symptoms for about four hours).
Q7. Can monitoring of
psycho-stimulant use and long-term outcomes provide a useful piece of
information in your opinion?
Such information might be
useful in preparing best practice parameters and identifying areas of varied
practice pre- and post- establishing such parameters.
It could also be
beneficial in examining long-term outcomes for medicated preschoolers for
which we have no data to date.
Q8. What new
pharmacological treatments are on the horizon for treating the symptoms of
ADHD?
There is a host of new
ADHD medications before the FDA for review, most trying to reduce dosage to
once a day. These are sustained release, long-acting preparations.
It is not known yet
whether there will be fewer side effects with one-dose medications. It was
suggested that more non-stimulant drugs needed to be studied for use in
ADHD.
Several narcolepsy drugs
were being looked at for use in ADHD. These are non-C2 (controlled
substances) drugs; so far, non-stimulants haven't been as effective.
Q9. Specifics on
psychosocial intervention for ADHD–
–What is the most
prevalent psychosocial treatment for those with ADHD?
The most prevalent
psychosocial treatments for ADHD include play therapy, cognitive therapy,
and individual therapy, but none of these has been validated as an effective
treatment for ADHD individuals, especially children.
Drug-only treatment,
administered by medical doctors, is the most prevalent form of treatment for
ADHD. The most prevalent psychosocial treatments have no studies supporting
their effectiveness.
–What is the typical
length of psychosocial treatment for those with ADHD?
The typical length of
treatment is unknown.
Parent training, when and
if it is offered, consists of 8-16 weekly sessions and should include
refresher courses. However, there are no studies on parent training
effectiveness for ADHD, on how best to deliver it, or on how well it is
currently administered.
–Is there empirical
support that early identification and initiation of psychosocial treatment
providing increased benefits or better outcomes?
There are no strong data
on this issue. The ideal way to ascertain if better outcomes were seen in
children who receive intervention as an earlier age would be to start with
the first day of school and collect measures of these children's reputations
for peer relationships as reported by their peers.
–Are the most prevalent
psychosocial treatments scientifically supported?
No. See above.
Q10. Describe the
empirical support for the use of psychosocial interventions in the treatment
of ADHD. Is it efficacious and how thoroughly has this area been researched?
See above.
It was noted by
participants that few psychiatrists are trained in behavioral therapy, but,
instead are trained in individual or group therapies. It was recommended
that training in medical schools include behavior modification training for
treatment of the disruptive behavior disorders like ADHD.
It was suggested that
parent training services be added to managed care service provision at the
gatekeeper level, especially since managed care organizations are reluctant
to refer patients out from the primary care giver. Professional associations
are proposing standards, but there is much dissent over this. A plethora of
protocols is not wanted.
Q11. In a research study,
what methodological issues would have to be addressed to allow for optimal
sensitivity of psychosocial treatment effects?
The following would be
needed:
End-point measures of
children off medication, including those who have had behavior therapy;
Outcome measures for
patients on and off active treatments;
Information about the
process;
Observation at
home/school, and maintenance and relapse support;
Multi-site study;
Parent/teacher rating
scales that show interactions.
Q12. Would you agree that
there is a reasonably valid method of identifying and treating ADHD in
children that could be applied uniformly across professional disciplines?
(Apply separately to adults)
Yes. See response in Q1.
Q13.
What are significant barriers to appropriate assessment and treatment for
ADHD? (Consider if insurance coverage plays a significant role
in the receipt of appropriate services and in what ways?)
Insurance coverage
oftentimes does not pay for parent behavior management education or full
psychological evaluations for behavioral disorders.
CDC could support groups
and policymakers to apply pressure for change in managed care practices and
coverage.
The impact of managed
care practices on treatment for ADHD has not been adequately assessed. For
instance, there may be an increase in stimulant prescriptions because
managed care will pay for pharmacological interventions and not psychosocial
therapy.
Additional barriers and
concerns include:
-stigma about stimulant
use
-diagnosis of ADHD
later in life
-managed care timed
visits
Q14. In what ways can CDC
as a public health agency address research needs or public policy in the
area of ADHD treatment at the level of the population?
CDC can influence parents
to look for early parent/school-based interventions for ADHD.
CDC could gather data
about practitioners, provide grants to professional organizations to work
with practitioners, and track the registry of insurance benefits. CDC could
also influence the addition of behavioral management into teacher education
programs.
CDC could provide
guidance on best practice for drug use by studying the risks and benefits of
this type of intervention in the population and, especially, among
pre-school children.
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