Abstract
A recent British television drama titled ‘Kid in the Corner’ canvassed many of the issues surrounding Attention Deficit Hyperactivity Disorder (ADHD) and related problems that are of concern to parents, teachers, and health professionals. The first episode begins with a trip to the supermarket by Danny, a primary-school aged child, and his parents. Danny is overstimulated by the experience and his excitable behaviour quickly draws disapproval from other shoppers. His father comments, by way of an apology, that dietary control has been ineffective. Later, a lunch with family friends is disrupted after it is discovered that Danny has gone on a cutting spree with a pair of kitchen scissors. At school Danny is teased because he has forgotten to bring his gym shorts. The punishment for his forgetfulness and poor organizational skills is to spend the gym class sitting on a mat. The teacher becomes very cross with Danny when she finds him, not only off the mat, but trying to climb a rope. Danny assaults the teacher when she attempts to physically restrain him, leading to suspension from school. His parents consult their general practitioner, who is unsympathetic to their concern about ADHD. Danny, after all, behaves perfectly well when he visits the surgery. The implication is that Danny's parents are pressuring for medication to compensate for their disappointment that he is not a high achiever. What Danny needs is more quality time with his parents. Counselling sessions are abandoned because the therapist seems to focus more on the marriage than on Danny. A paediatric consultation does eventually lead to a trial of psychostimulant medication that helps to improve Danny's concentration and reduce his hyperactivity. However, Danny remains oppositional and has other problems including deficits in social skills and low selfesteem. Following an episode of deliberate self-harm Danny is transferred to a residential treatment facility.
‘Kid in the Corner’ illustrates well the stress on family members when a young person is affected by ADHD. It also illustrates the double standard present within the community: ‘We do not approve of your child's behaviour, but we also do not approve of you invoking the diagnosis of ADHD to explain it’. Danny's problems are not restricted to poor attention and hyperactivity, and it is unlikely that psychostimulant medication alone will be enough to help him. Dysregulated affect is as much of a problem to Danny's parents and his teachers as his hyperactivity. There is a reciprocal interaction between Danny's behaviour and his environment. Finally, anticipation and a certain degree of flexibility on the part of teachers and parents could go some way to alleviating Danny's difficulties. If only the gym teacher had accepted Danny's suggestion that he borrow a pair of shorts from ‘lost property’…
Attention Deficit Hyperactivity Disorder continues to receive a disproportionate amount of media attention relative to other psychiatric disorders of childhood. Recurring themes include the concern that the medical profession may be pathologizing normal childhood behaviour, and reservations about the use of drugs that have the potential for abuse as first line treatment. Evidence for ADHD being more than a benign self-limiting condition comes from longitudinal research that shows symptoms persist into adolescence and adulthood in 40–70% of cases [1]. Importantly, children with moderate to severe ADHD symptoms are also at increased risk of developing other problems such as anxiety, mood disorder, antisocial behaviour, and substance abuse [2]. The pattern of behaviour over time is probably the key feature in distinguishing children with ADHD from those with other disorders or no developmental problems. If there is a criticism of current diagnostic practice, it is that too much emphasis is given to cross-sectional assessment [3, 4]. When there is uncertainty about the diagnosis, clinicians would be well advised to extend the assessment observation period over several months. This is especially true for preschool children, as research has demonstrated that the diagnosis of ADHD is unstable in this age group [5]. General practitioners are in an excellent position to provide this longitudinal perspective, but are an underutilized resource.
A question often asked by parents is whether longterm exposure to psychostimulant medication will increase the likelihood that their child will engage in substance abuse. Despite recent concerns expressed in the media, the evidence from a systematic review of naturalistic studies suggests not [6]. The authors of the review concluded that, if anything, responsible treatment of ADHD with psychostimulant medication protects against subsequent substance abuse [6]. The mechanism is likely to be via a reduction in the risk of associating with youth with antisocial traits who may promote, and indeed supply the materials for substance abuse. Are prescribed psychostimulants misused by some patients, their families and associates? The answer is almost certainly yes, but the extent of the problem is unknown owing to its covert nature. Personal communication from parents suggests that some teenagers do give or sell their tablets to peers, although the volume is likely to be small. Where there is a suspicion of personal or familial substance abuse, clinicians obviously need to be wary of prescribing psychostimulant medication. Slow release preparations of psychostimulant medication that are not presently available within Australia would allow for once daily dosing that could be better supervised by parents, and markedly reduce the need for teenagers to take their medications to school.
The short-term efficacy of psychostimulant medication in reducing the target symptoms of ADHD is well documented [2]. The sixth edition of ‘Clinical Evidence’, which tends to be conservative in its conclusions, lists methylphenidate and dexamphetamine as of likely benefit for ADHD [7]. At first glance this may seem a case of the psychostimulants being damned by faint praise. However, meta-analysis of data from multiple trials, generally considered the highest order of clinical evidence, has been problematic owing to the lack of an agreed statistical method for pooling data from crossover trials to obtain a summary estimate of treatment effect. More controversial is the question of whether psychostimulant medication offers any long-term benefit to children. This is a difficult case to prove, as is the case for the long-term benefit of intervention for any disorder, because there are many uncontrolled variables. However, one randomized controlled trial of amphetamine administered over 15 months found persistently lower scores on parent and teacher ratings of the behaviour of children receiving active treatment compared with those receiving placebo [8]. Placebo-controlled trials are unlikely to be conducted over periods longer than 15 months, as it would be considered unethical to deny children access to a treatment that has proven short-term benefit.
Published practice guidelines generally advocate that the treatment of children with ADHD should incorporate several modalities [3, 4]. Typically this means medication combined with advice for parents about behaviour management, and classroom support for the child to facilitate learning and minimize disruptive behaviour. The results of the Multimodal Treatment Study for ADHD (MTA study) conducted at multiple sites in North America challenge this view, because on the whole, children treated with psychostimulant medication alone did as well as those receiving multimodal treatment, and rather better than those receiving only behavioural management [9]. Commentators have noted that for the ‘medication-only’ group there was still substantial contact between the research clinicians, the children and their parents; the implication being that the families would have received considerable support and non-specific counselling. And so they should, as we would hope that clinician prescribers maintain an active interest in the wellbeing of the child and family beyond the technical aspects of monitoring treatment.
There is ample advice available to clinicians concerning the initiation of pharmacotherapy, but remarkably little information about when and how to cease treatment. Data from a survey of parents of children in the Hunter region of New South Wales treated with psychostimulant medication suggest the obvious, namely that children continue with treatment when it is helpful, and discontinue when it is not [10]. Therefore, a reasonable approach is to allow the decision about the continuation of treatment to be guided by the child and parent's perception of benefit. Unfortunately some treatment non-responders are lost to follow-up, or resurface several years later with significant secondary behavioural and educational problems. This can be prevented if adequate attention is given to establishing and maintaining a therapeutic alliance. Much emphasis has been given in practice guidelines to the technical aspects of the management of children with ADHD. However, the survey of parents in the Hunter region whose children were treated with psychostimulant medication found that good basic clinical practice such as conducting a considered assessment, providing good information to parents, and reviewing the patient at intervals of three months or less, were associated with a favourable treatment response [10]. These are clinician behaviours that facilitate rapport. There is much to be said for old-fashioned good doctoring.