Washington - Health-care professionals, educators and patient advocates debate endlessly over attention deficit disorder.
Some argue about the cause of the condition, which is associated with inattentiveness and, often, hyperactivity. Many disagree on treatment and parenting techniques. A dwindling group disputes whether it actually exists. Even its name - to be formal, it's attention-deficit/hyperactivity disorder - has been a source of debate.
The label ADHD trivialises the disorder, asserts Russell Barkley, a neuropsychiatrist and professor of psychiatry and paediatrics at the Medical University of South Carolina who has published more than 300 peer-reviewed articles on the condition.
“ADHD is not simply about not being able to pay attention. Describing it as such is like calling autism a 'not looking at people' problem,” he said, and there is much more to ADHD.
Some practitioners and researchers say drugs are by far the most effective treatment. Others argue that long-term drug use addresses symptoms only and does not provide important tools to help people manage their inattentiveness. They say it's more helpful to focus on behavioural interventions, nutrition, exercise and special accommodations at school.
The American Psychiatric Association says there is no doubt that ADHD exists - and it estimates that five percent of US children have the condition.
The Centres for Disease Control and Prevention puts the figure higher, reporting that 11 percent of US children age four to 17 had been diagnosed with ADHD as of 2011.
Whatever the number, many parents of kids with attention problems struggle with how best to help them. They seek guidance on whether to medicate. They want to know how to advocate for them in school and with their doctors. They look for ways to help them grow into well-adjusted, successful adults.
Science recognises ADHD as involving brain development, although there is disagreement over what exactly happens in the brain to trigger ADHD symptoms. Barkley says there is an inherited aspect, though he also says the condition is sometimes triggered by environmental factors such as exposure to smoke and alcohol before birth. ADHD impairs self-regulation of behaviour and emotions. And it impairs regulation of thoughts involving planning, organising and problem-solving, he said.
Research shows that the maturation of brain regions associated with these functions is delayed by about three years in people with ADHD. Studies also suggest that these regions are smaller than normal and that they are less active. Also, imaging tests show dysfunctions in the networks of nerve cell fibres that allow brain regions to communicate with one another.
“Some of these networks affect working memory, which allows us to retain information. This explains the forgetfulness and difficulty completing tasks,” Barkley says. “A network tied to timing of our actions explains why these people are chronically late. A network tied to impulse control explains why they have five times more speeding tickets and why their relationships often head south. A network affecting ability to sustain attention is why they, for instance, have three times more car accidents.”
Whether children should be treated with medication sets off debate. “Some families say medications changed their child's life for the better; others tell you horror stories,” said Ruth Hughes, former chief executive of Children and Adults with Attention-Deficit/Hyperactivity Disorder.
Advocacy groups such as CHADD suggest a mixed approach that may include medication but also entails the application of parenting skills, behavioural interventions and school support.
Studies have produced contradictory results on the effectiveness and safety of medications for ADHD. A 2014 article in the Journal of Health Economics, based on a 14-year study involving 8 643 children with ADHD, concluded that “expanding medication... had little positive benefit and may have had harmful effects, given the average way these drugs are used in the community.” Yet a 2014 meta-analysis of 25 studies concluded, “Short-term [drug] treatment is safe and superior to placebo for ADHD symptoms and secondary outcomes.”
Hughes says parents should decide with their children's doctors whether to use medication; for additional advice, she recommends “ADHD: Parents Medication Guide,” a booklet prepared by the American Academy of Child and Adolescent Psychiatry and American Psychiatric Association.
“It's based on science, but it's not all about 'Yes, medicate your kid,' “ Hughes said. “It takes a thoughtful approach.”
Hope Scott, a developmental paediatrician in Reston, Virginia, prescribes medication to most of her ADHD patients. But drugs are only one part of the plan.
“Medications improve distractibility,” Scott said. “But they do not touch development of time management or organisational skills. They help you focus on cleaning your room, but you still need to learn how to do it.”
To teach such skills, she suggests ongoing behaviour management measures such as reward tokens redeemable for such things as sleepovers with friends. Scott also recommends educational support, including classroom accommodations, such as more time to take tests or working on homework assignments during school hours for students who can't focus after a full day of school.
Nitya Ramachandran, an Olney, Maryland, integrative paediatrician focusing on nutrition and other complementary and alternative medical protocols, has parents keep a diary noting what their children eat and when their symptoms worsen. Some studies, including a recent one in European Child Adolescent Psychiatry, suggest that food additives provoke ADHD behaviours, though the National Institutes of Health reports only a small percentage of children improve by restricting these additives.
“From the diaries and what parents tell me, many kids find it harder to focus, are tired or hyper when they eat processed foods and, in some cases, food additives like artificial dyes,” Ramachandran said.
Sometimes symptoms subside when these ingredients are eliminated. Ramachandran prescribes fish oil and probiotics to promote nutrient absorption. She checks thyroid hormones, vitamin D and iron levels - studies suggest deficiencies in these areas may be associated with ADHD - and emphasises the importance of sleep.
Nearly 70 percent of her patients take low-dose medication; about half are weaned off them once they can focus on academics and their stress levels subside - usually within several months.
“They do well,” she said. “But they follow this integrative approach looking at overall health.”
ADHD is hard to diagnose because there are usually coexisting conditions with related symptoms, such as obsessive-compulsive disorder or learning disabilities including dyslexia, said Barry Ekdom, a Fairfax, Virginia., neuropsychologist. Like many neuropsychologists, he assesses for ADHD by taking the patient's history and testing several functions such as memory retrieval, which in some cases may be an indicator of ADHD and or other cognitive problems.
“People with ADHD get it when they study, but they blow the test - that is memory retrieval. The knowledge is learned and remembered. But they can't retrieve it when questioned,” Ekdom said.
He suggests having ADHD children practice accessing information, such as repeatedly answering review questions before a test rather than simply reading material to be covered.
Auditory and visual cues - such as to-do lists and recorded messages - can help, some experts say.
Cary Euwer, a 29-year-old from Chevy Chase, Maryland, did well in high school, dealing with ADHD by studying late into the night and getting up early. The increased demands of college were too much for him. He lacked organisational skills and he couldn't focus.
A turning point came when he took a college class where he was helping fourth-graders with science, a subject he loved but struggled with. “The way I was taught was too abstract for me. But I got to do hands-on work with these kids, which was more concrete and made it easier.”
Euwer also worked with a coach from the Edge Foundation, a national nonprofit that offers assistance to people with ADHD. “We focused on organisation strategies like breaking tasks in small steps. We worked on time management, to help me think about how long something would take and planning ahead.” Taking breaks and exercising were also tremendously helpful.
The coaching, he said, helped him learn how his mind worked. Now he is completing a graduate programme at Maryland Institute College of Art in Baltimore, focused on developing design concepts (such as communications tools) to address social problems.
“Once I had skills,” he said, “it was okay that I have a million thoughts coming at me at once.”
The medication debate
To medicate or not?
This decision is stressful for parents who see a child struggling with ADHD but who worry about tampering with brain chemistry.
Websites offer wildly mixed messages about ADHD meds, studies show conflicting data about whether they work, and doctors don't always agree. Some friends and relatives can't imagine “how you could drug your child,” while others wonder why you would reject something that might help.
But clinicians who treat ADHD say the decision is often fairly straightforward.
“I recommend medication when something causes a child to be unable to thrive in his environment,” said Glen Elliott, the chief psychiatrist at the Children's Health Council in Palo Alto, California, and author of “Medicating Young Minds: How to Know if Psychiatric Drugs Will Help or Hurt Your Child.”
Elliott is familiar with the dilemma parents face: His son struggled with ADHD in high school and finally opted to use a stimulant occasionally in medical school.
Stimulants such as Ritalin, Adderall and Vyvanse are nearly always the first medication doctors try, Elliott said, because they have a long, solid safety record, they take effect within minutes and they leave the body within hours.
Timothy Wilens, chief of child and adolescent psychiatry at Massachusetts General Hospital, said he weighs factors such as age, severity of symptoms and how the symptoms affect the child's outlook.
“If I have a child who is relatively younger, with mild symptoms, I am slower to recommend medications. I may first request environmental changes at school, or a different daily structure at school or at home,” he said. “Contrast that with an 11-year-old who is struggling greatly in class, having problems paying attention, getting distracted, and becoming phobic about homework. That child is clearly on a different trajectory than what he should be and would probably benefit from medication.”
(Wilens and Elliott received personal funding from pharmaceutical companies in the past but do not do so now.)
Many ADHD groups and both major US child psychiatry organisations (the American Academy of Child and Adolescent Psychiatry and the American Psychiatric Association) recommend medication for ADHD, usually in conjunction with therapy that teaches strategies to help with skills such as organisation and time management.
Managing expectations is key, however, because no drug can cure ADHD. While some people with ADHD naturally become less symptomatic as their brains mature, Elliott said, about a third of people with ADHD will need treatment their entire lives.
Here are some pros and cons of ADHD medication, according to experts:
Pros
* In addition to being well-tolerated, approved by the Food and Drug Administration and easy to try out - because they enter and exit the body quickly - stimulants are not addictive in the doses prescribed for ADHD.
- Stimulants can be effective even if taken only occasionally.
* Drugs may reduce some of the longer-term problems associated with untreated ADHD, such as depression and substance abuse.
Cons
* Side effects range from mild (and common) - such as irritability, sleep disruption, drowsiness and loss of appetite - to serious (but rare) - such as heart and liver problems and exacerbation of mental health issues.
* Clinicians disagree on whether people build up a tolerance for stimulants.
* No drug has proved effective for executive function problems.
* Some can be stolen or resold, which can lead to abuse.
* Effects are short-term, in that none can cure ADHD.
Washington Post