Experts meet to discuss the hot topic of ADHD

The 54th American Academy of Child & Adolescent Psychiatry (AACAP) Conference has recently been held in Boston. International and local experts attended to discuss a broad range of issues in child and adolescent psychiatry. The topic of Attention Deficit Hyperactivity Disorder received particular consideration given recent controversies surrounding treatment of children with stimulant medications.

ADHD is one of the most common behavioural disorders of childhood. ADHD is characterised by a persistent pattern or poor attention, hyperactivity, poor impulse control and distractibility.

It is estimated to affect approximately 5.2% of the world’s population. Rates vary largely between countries partly due to variations in diagnosis mechanisms. Approximately 60% of cases present in childhood. ADHD does not only affect children and up to two thirds of patients have persistence of their symptoms into adolescence and adult life.

In Australia we use the DSM-IV criteria for diagnosis which is the current gold-standard. To meet a diagnosis of ADHD your child must have 6 out of the 9 listed symptoms of the disorder. Symptoms must develop before the age of 7 years and be present for at least 6 months.

Diagnosis can be a bit trickier in younger children as many of the symptoms (such as motor hyperactivity) can merge with normal childhood behaviour. Nonetheless, the condition is thought to affect about 2% of children aged 3-5 years.

The cause of ADHD is not entirely understood but genetics is involved as approximately 80% of cases having a positive family history. Factors such as smoking or alcohol use during pregnancy and low birth weights are also thought to play a role. More recent research suggests that a special coordinating system in the brain may be responsible for the inattention and distractibility.

ADHD can be a serious disorder and lead to significant impairments in your child’s social and educational functioning. Children with ADHD can experience lower rates of school and career achievement and increased rates of substance abuse and risk taking behaviours. More than half those with ADHD have other psychiatric conditions which leads to increased impairment and difficulties in treatment.

Treatment is therefore important both for reaching academic and social potential and to avoid the increased risk of drug and alcohol abuse and other dangerous behaviours. Medication does not add to academic or sporting ability but may enable the underlying ability to be sustained.

At the 54th American Academy of Child & Adolescent Psychiatry (AACAP) Conference several experts discussed the various treatment options for ADHD. In the past there has been a lot of media hype surrounding the use of stimulant medications in young children and their potential for abuse. However there are now a wide variety of approved treatment options for ADHD including stimulant medications (such as amphetamine or methylphenidate preparations such as Concerta or Ritalin), the non-stimulant atomoxetine (Strattera), and behavioural treatments.

A study discussed by Dr. Lawrence Greenhill of primary school age children, found that medication was more effective than behavioural treatment, with medication plus behavioural treatment giving the best results. Furthermore, lots of different stimulant drugs have been developed with different durations of action to better suit your child’s individual needs.

For example if your child needs to do homework in late afternoon, a longer duration preparation may be suitable. Some anti-depressants may also be used as alternative treatments.

During the conference Dr. Greenhill also presented breaking research about the use of stimulant medications in pre-school children aged 3-5.5 years. He found that drugs can be beneficial in this group (with 85% of children showing improvement) but the overall effects were not as great as with older children. However this is exciting news as the use of these drugs in this age group has been previously warned against. Only very severely affected children were included in this study but if children are found to correspond to the patients in the trial, it is likely they will also respond to medications.

At the same conference Dr Timothy Wilens spoke on the treatment of resistant or complex ADHD. This equates to the 30% of patients who do not respond to or who cannot tolerate first line agents. He stressed the use of high doses and pushing the dose to achieve ‘wellness’, not just take the edge off symptoms.

He also discussed the benefits of using combinations of drugs in children with other psychiatric problems and attempting to treat the most severe of the co-morbid disorders first. As a parent you should attempt to inform yourself about the uncertainties of diagnosis, the properties of the various drugs, their expected side-effects, and the risks of not treating.

Good information is available from ‘parentsmedguide.org’ and from the ‘tool kit’ on the website of the American Academy of Pediatrics.

You should be wary of stimulant side effects such as appetite suppression; slower growth in weight and height; abdominal discomfort; headache and difficulty in getting to sleep. In addition, pre-schoolers may be more susceptible to tantrums, bouts of crying and irritability. Atomoxetine (Strattera) may also cause nausea, vomiting, dyspepsia, dizziness, fatigue, decreased appetite and irritability. Treatment with these drugs therefore requires careful monitoring of height, weight and cardiovascular factors.

It is important you consider all these factors when deciding on appropriate treatment for your child. This new research will hopefully allow the medical profession to improve the treatment of ADHD. Greater knowledge regarding the drugs and the side effects can help in deciding the best treatment options for your child. Better treatment of ADHD will lead to improvements in overall quality of life for patients and their caregivers.

In all circumstances it is recommended you discuss your treatment options in detail with your treating doctor and whether the above medications are suited to you.