Public Health Issues in the Treatment of ADHD
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June 15, 1999
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?
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;
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.