Medicating ADHD: Too much? Too soon?

The controversial subject of medicating children with attention-deficit hyperactivity disorder (ADHD) was the focus of several APA 2001 Annual Convention sessions. Among them, Div. 53 (Society of Clinical Child and Adolescent Psychology) sponsored a panel discussion for leading clinicians and researchers and collaborate on solutions, presenting varied concerns about how we treat children for ADHD in the United States.

Some contended that professionals overdiagnose and overmedicate children with the condition. Others posited that medicines such as Ritalin are an ADHD child's best chance for normalcy. Most advocated measured, combination treatments for the disorder.

Among the experts in the area is Gretchen LeFever, PhD, of Eastern Virginia Medical School--one of the few researchers systematically collecting epidemiological data on the extent of medication use for ADHD. Although as a clinician she has made hundreds of referrals for medication trials and medication management, LeFever asserts that the amount of drug treatment outpaces ADHD's prevalence.

To support her view, she pointed to a study in which she compared ADHD medication rates in Virginia with several other states to generate a national picture of ADHD drug treatment. School records from two Virginia school districts alone revealed that the rate of ADHD drug treatment was two to three times higher than the national estimates for the disorder.

In her study, LeFever found that 84 percent of children with ADHD received medication at some point in time, and 70 percent were receiving it at the time of the survey--which spanned the summer months during which a medication hiatus is often recommended. The only children who had never received drug treatment were uninsured, she found.

In addition, 28 percent of the elementary school students who were medicated for ADHD in LeFever's study received two or more psychotropic drugs simultaneously. For many of them, treatment began during preschool or early childhood years.

To reduce rates of medication, LeFever called for "a public health agenda that includes improved systems for tracking ADHD diagnoses, treatments and outcomes and primary prevention initiatives."

Another speaker, University of California at San Francisco clinician Lawrence Diller, MD, agreed with LeFever's position on overmedication. Diller said that while he has "no doubt that Ritalin works, certainly in the short term," no one talks about a moral equivalent: "better parenting and more appropriate schooling for children."

Research on medication

Taking a different tack, Columbia University's Peter Jensen, MD, presented data to disprove that behavioral therapy--even the most intensive parental training and teacher consultation--manages ADHD as effectively as medication.

Jensen cited the NIMH Collaborative Multisite Multimodal Treatment Study of Children With Attention-Deficit/Hyperactivity Disorder (MTA), of which he, presenter William Pelham, PhD, of the State University of New York at Buffalo and six others were lead investigators.

The study tested four treatment options--combined pharmacological and intensive behavioral therapy, medicine alone, intensive behavioral therapy alone and "usual care," leaving families with the choice of treatment they would seek from their community providers. This option thus included medication with methylphenidate for 70 percent of the cases.

Jensen reported that the researchers found children's inattention and hyperactivity could be equitably managed with both intensive combination and pharmacological treatments, but that combined treatments more successfully treated "domains of functional impairment" such as aggression, defiance and poor social skills than medication alone.

At the end of his year-long study, Jensen reported, 68 percent of participants in the combined group met the criteria for ADHD normalization--a reduction or complete discontinuation of the behaviors, such as extreme aggression and lack of concentration, that set ADHD children apart from their peers. In the medication management group 56 percent met normalization criteria, in the behavior therapy group 34 percent reached normalized and only 25 in the community-care groups did likewise.

"On the clinical level these results have an impact," he said. "I'd hate to deny medication if there is a substantial possibility of normalizing a child in the classroom."

But as the percentages reveal, medication is not the only effective nor, Jensen emphasized, always the best treatment option for every child. When his own child was diagnosed with ADHD, Jensen told the audience, he and his wife opted not to use medication.

To another proponent of medication, Russell Barkley, PhD, of the University of Massachusetts, the real question is "why our country does not invest very easily in early identification, intervention and wide access to treatments." Research shows ADHD to be "a largely an inherited disorder with substantial neurological underpinnings, for which medication has been an extraordinarily effective means of treatment," Barkley said. Yet he believes fewer than 50 percent of children with ADHD are ever treated for their disorder. Thus, the debate first hinges on which children should be diagnosed with ADHD, and then how they should be treated.

To the critics who point to countries with lower rates of diagnoses and medication of children for ADHD, Barkley said, "So what? We do not let the rest of the world set our standards of care when we do more research on childhood disorders--specifically ADHD--than other countries combined?"

Such criticisms, he said, point to the fact that society may have forgotten what its mission is: "the relief of suffering and impairment. If the use of medication helps us do that job, stop hand-wringing about the extent to which we are using medication in this country."

On the other hand, both Pelham and Diller noted the absence of data that demonstrates medication's long term efficacy with ADHD children. "Their poor prognoses are not altered at all by medication" Pelham pointed out. "The effects are only there for as long as they take medication, and 90 percent of ADHD children stop taking it in adolescence."

Combination treatments

Pelham, who chaired the panel, also reported on the parent and teacher satisfaction with treatments in the MTA study and shared their one-year follow-up data. He pointed out that children treated with behavioral methods had shown dramatic improvement regardless of the fact that those who remained actively medicated were functioning better in terms of ADHD symptoms. However, the nature of the intervention produced dramatically different results for satisfaction with treatment: With medication alone there was a much higher rate of dropout from the treatment and much greater parent and teacher dissatisfaction with the results, in addition to a significantly lower rate of very positive satisfaction.

By comparison, parents and teachers much preferred a combination of pharmacological and behavioral treatment and behavioral treatment alone. These options had far lower dropout rates and much lower dissatisfaction, and also appeared to produce results with more staying power after one year of treatment.

These results are important, according to Pelham, because they reveal that "ADHD is a chronic disorder that requires chronic treatment, and interventions must be palatable to parents and teachers in order for them to continue over the long haul," he said.

The one-year follow-up data from the MTA showed the effects of combined treatment were superior to medication alone in terms of the percentage of children normalized. So too, Pelham demonstrated that "behavioral treatment and medication were not substantively different in most domains of functioning and in rate of normalization after one year," he said. Pelham and his research partners concluded "the results of the behavioral treatment maintained, while those for medication diminished somewhat, even though the medication was still actively being given at a high dose."

"Parents need to be presented with a choice," he said, concerned that, in actual practice, the risks and benefits of medication are rarely presented. Wider treatment options, he said, "will help normalize functioning of many ADHD children without medication. For those children for whom behavioral treatments are insufficient, the addition of medication can be very valuable."

In the end, said Charles Cunningham, PhD, of McMaster University, the most salient points to examine are whether parents receive a balanced description of all possible interventions, whether both children and parents participate in the service-delivery process, and whether there is equitable funding for all proven treatments.

He called upon his colleagues to invest "the same time, effort and money in improving the performance of our psychosocial interventions that we are on our pharmacological interventions."