Is Pharmacotherapy the Best Treatment for ADHD?
By Eriene-Heidi Sidhom, Brian Wolf
Brian Wolf argues that pharmacotherapy is the best treatment for ADHD but Eriene-Heidi Sidhom believes behavior therapies and other individualized treatments are necessary to move treatment forward.
There is a growing number of children who have been diagnosed as being unmindful, hyperactive, and impetuous and then labeled ADHD. Consequently, when properly diagnosed, effective treatment for attention-deficit hyperactivity disorder (ADHD) is needed to control these symptoms. Diagnosed in the 20th century as the first psychiatric disorder to be treated in children, studies of stimulant treatment have been conducted since the 1930s and regulatory approval of stimulant treatment for children began the 1960s. ADHD, a complex disorder, is due to a combination of genetic, environmental, or biological risk factors that can exacerbate the vulnerability of a child to this disorder. 1 Currently, in the 21st century, the use of stimulant drugs for ADHD has come under scrutiny due to potential side effects that result from the medication. Through comprehensive medical, developmental, educational, and psychosocial evaluations, a doctor can properly diagnose a child for ADHD and then provide either a closely monitored medication treatment or a program that combines medication with intensive behavioral interventions.
For over 40 years, the main treatments for ADHD have been the stimulant drugs, methylphenidate and amphetamine (Ritalin and Adderall), which are believed to increase the neurotransmission of dopamine and norepinephrine. Over the past decade, there has been concern about the duration of the drug treatment. In a double blind, placebo-controlled study conducted in 2002, the objective of the study was to compare the efficacy, safety, and tolerability of a once-daily administration of modified-release methylphenidate with placebo in children with ADHD. 2 The results of this study suggested that a once daily modified-release methylphenidate, given in the morning, is effective and safe in controlling ADHD symptoms during a school day. However, in this study, there was significant evidence that anorexia occurred at higher rate in the drug treatment group than in the placebo group. It is also important to note that this study was conducted over a three-week period and the long-term effects of this medication were not being investigated. Doctors need to properly diagnose their patients’ progress and ensure that the drug treatment is working effectively. If the drug treatment is not effective, the doctor needs to make changes to this treatment. Through close monitoring of the progress of the ADHD drug treatment, the child’s safety and health will be of the utmost importance.
In combination with the drug therapy, behavioral treatment has been proven effective in treating children with ADHD. The practice of behavioral modification, which uses reward and response cost to change behavior, has shown positive results. In a long-term study that compared various practices to control ADHD symptoms, combined treatment and drug management groups showed greater efficacy than behavioral treatment and community-care groups. 3 These analyses suggest that, for children with ADHD, drugs should first be considered for treating this disorder. However, it should also be noted that only relying on behavioral treatment could also be valuable for some patients. Other findings suggest that, after drug treatment is under control, assessments of residual disabilities should guide subsequent decisions regarding behavioral therapy. By merging drug treatment and behavioral therapy, the health and safety of children with ADHD will be better managed and possibly reduce the possibility of side effects, such as anorexia.
Despite decades of clinical use, stimulant drugs are considered to be controversial due to potential side effects that have proven to be false. For example, early reports that showed stimulants caused an increased risk for tics in patients with a personal or family history of tic disorders have been challenged over the past decade. In a study published in Neurology in 2002, the results concluded that prior recommendations to prevent usage of methylphenidate in children who had tics because of apprehensions of worsening tics are not supported by this trial. 4 Additionally, because stimulant drugs are controlled substances with addictive potential, there have been concerns that children with ADHD are prone to abuse and addiction of these drugs when used for many years. Studies on this issue have shown that stimulant drug therapy in childhood is actually related with a reduction in the risk for subsequent substance use disorders. 5 While side effects of increased risk for tics and substance abuse are proven false, stimulant drug therapy for children with ADHD still needs to be closely monitored (e.g. correct dosages) to maintain a healthy lifestyle for these children.
Current research has been conducted on the risk of cardiovascular events (e.g. sudden cardiac death and stroke) due to stimulant medication for ADHD. In an article published this year in The New England Journal of Medicine, a large study (funded by the Agency for Healthcare Research and Quality and the Food and Drug Administration) indicated that there was no evidence that current use of an ADHD drug was connected with an increased risk of serious cardiovascular events. 6 More studies similar to this one need to be conducted to ensure that the safety of the children who take these drugs is maintained. For example, if there are significant side effects due to the drug treatment that cannot be controlled by changing dosage amounts, then the patient should be taken off a drug treatment and seek alternative treatments. Proceeding cautiously with drug treatments for ADHD remains the main objective for doctors to help alleviate the symptoms of ADHD.
1. Biederman, Joseph, and Stephen V. Faraone. “Attention-Deficit Hyperactivity Disorder.” The Lancet 366.9481 (2005): 237-48. Print.
According to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV), attention deficit hyperactivity disorder (ADHD) is defined as “persistent pattern of inattention and/or hyperactivity – impulsivity that is more frequent and severe than is typically observed in individuals at a comparable level of development”. 1 For over 50 years methylphenidate (Ritalin) has been used as the gold standard to treat ADHD. However, in 2009 in the UK, the National Institute for Health and Clinical Excellence (NICE) changed its guidelines for diagnosing and treating ADHD in children stating that behavioral therapies, rather than medications, should be used as the first line of treatment. Furthermore, it stated that methylphenidate should be used only in extreme cases. 2 This change in treatment follows increasing concerns of the overprescribing of methylphenidate to young children. The main questions of both professionals and the general public concern the diagnostic criteria, the adverse effects of both the syndrome as well as medication and what is the optimal treatment for ADHD. 3 Despite methylphenidate being the standard for treatment, its use is not always merited in the treatment of ADHD, due to its potential for adverse effects, the possibility of other effective treatments, and the expanding definition of the disorder.
There are those who believe that methylphenidate has proven to be an effective treatment and therefore should continue to be used as the first line of treatment. Being the standard for treatment, there have more than 170 studies involving more than 6,000 school-aged children using a stimulant medication for ADHD treatment. For all stimulant drugs, the average response is about 70%, and 90% of children will respond to at least one medication without major adverse effects. 3 Furthermore, magnetic resonance imaging studies of ADHD patients have shown abnormalities, suggesting that ADHD is a neuropsychiatric condition. 3 Therefore, methylphenidate addresses the neurological abnormalities by increasing dopamine levels in the brain. Additionally, the motivation to change the NICE guidelines to a more behavior-therapy focus can be seen as purely financial, as the usage of methylphenidate and other stimulants cost the NHS £13 million in 2004. 2 These extensive studies, supporting the effectiveness of methylphenidate and other stimulants in treating ADHD, has led many to remain confident that it is the best treatment for this syndrome.
While there is a breadth of scientific evidence for the effects of methylphenidate and other stimulants on children with ADHD, the absence of studies for adolescents and older age groups has raised concerns about the long term effects of these medications. Pharmacotherapy has also not been shown to have any long-term effects on any of the symptoms of ADHD, including classroom behavior, impulsivity, etc. 3 The reliance on stimulant therapy for ADHD is cause for worry because ADHD has been shown to be correlated to earlier onset of Psychoactive Substance Use Disorder (PSUD); one study of 388 participants, PSUD showed an onset on average of three years earlier in adults with ADHD. 4 Another study of 200 participants with a history of PSUD, showed that those with ADHD had a duration time of PSUD that was 37.2 months longer. 5 Therefore, the lack of information on the long-term effects of the stimulant medication, combined with the increased risk that those with ADHD have towards PSUD raises the question of using an alternative treatment.
With the growing concerns of stimulant treatment for ADHD, other treatments, including behavioral therapy, are gaining recognition as potential alternatives to treatment, or to complement current treatment. It seems natural that behavioral therapy would be the main treatment for ADHD as the diagnosis is based on a list of behaviors. 2 This view is clearly reflected by professionals: 98% of child and adolescent psychiatrists, surveyed in the UK, stated that a combination of behavioral and pharmacological therapy is the most effective treatment for ADHD, but only 34% said they used this combination on all their patients. Therefore, the issue is not recognition of the necessity of behavioral therapy, but some other barrier; these same professionals listed parental concerns and limited resources as the barriers to implementing behavioral therapy.6 Indeed, in a society where everyone is looking for a “quick fix” it is difficult to convince parents to change a treatment plan that appears to be working or to convince parents of newly-diagnosed children that deviating from the standard treatment will be as effective. The lack of resources is evidence to the amount of work necessary to make the transition from a stimulant-focused therapy to a behavior-focused therapy. In fact, the change in the UK of the NICE guidelines will probably cause a redirection, not a reduction, of funds and additional funding will probably be necessary during the transition period to supply education and to set up more behavior therapy services. 2 Shifting to behavior therapy as the focus of treatment for ADHD is not a financial strategy, but rather a logical strategy based on the currently defined diagnostic criteria for the syndrome.
The use of stimulants as a general treatment for ADHD implies that there is a single cause and a single manifestation of ADHD. However, the ever-changing and ever-expanding definition of the syndrome is evidence that the different manifestations are unique and therefore deserve a more personalized treatment, not provided by pharmacotherapy. When ADHD was first defined in DSM-III, it was divided into three behavioral dimensions (attention, impulsivity, and hyperactivity) with two subtypes (with and without hyperactivity). In the DSM-III-R it was modified to have one-dimensional criteria, but in the DSM-IV it was changed again to have two behavioral dimensions (inattention and hyperactivity/impulsivity) with three subtypes (predominantly in attention [ADHD-AD], predominantly hyperactivity [ADHD-HI] and combined [ADHD-CT]). The categories defined by the DSM-IV clearly exhibit the heterogeneity of the disorder, and it is further emphasized by the manifestation of the symptoms. In a study of 398 teachers, evaluating 8,258 children the difference between academic problems and behavior problems among the three groups showed strikingly different trends: among ADHD-AD children 78% had academic problems, while 40% had behavior problems; among ADHD-HI children 23% had academic problem, while 83% had behavior problems; among ADHD-CT children 92% had behavior problems, while 73% had academic problems. 7 Therefore, while there are those who justify the increased usage of stimulants on the expanding definition of ADHD, this expanding definition also reveals the diversity of those affected and therefore calls for a more personalized therapy, rather than a homogeneous and standardized therapy.
While it may be tempting to see methylphenidate as a “quick fix” for ADHD, according to the diagnostic criteria and the heterogeneity that it implies, a more personalized behavior therapy is perhaps better suited as the focus of treatment. The long history of methylphenidate as a treatment for ADHD has resulted in a large number of studies focusing on its short-term effect in children. While the results of these studies are very promising, the lack of long-term studies into adolescence and adulthood is concerning, considering the persistence of the disorder in many of those who are affected. Furthermore, the propensity of those with ADHD to suffer from PSUD should cause greater caution in using stimulant therapy. Therefore, the more logical approach to a behavior-based diagnosis is behavior therapy. The majority of professionals agree that behavioral therapy is necessary, but there are significant barriers to its implementation. However, if it were to be implemented it would allow for greater personalization in ADHD therapy, which is necessary due to the wide range of symptoms and severity in individuals. Although the adjustments to the NICE protocol may have angered those reluctant to change, it is perhaps a necessary step in moving ADHD treatment forward.
1. Gant, Charles E., Karen L. Harding, and Richard D. Judah. 2003. “Outcome-Based Comparison of Ritalin® Versus Food-Supplement Treated Children with AD/HD.” , 08; 2011/10, 319+.