|
Although the research evidence suggests that medication is effective alone, and may be the most effective part of comprehensive multimodal management (Wilens and Biederman 1992; Greenhill 1992), it is the general consensus that educational and behavioural strategies add to the success of management and are essential if medication is ineffective. There is considerable pressure to treat ADHD with its disruptive symptoms, associated learning, behavioural and emotional problems, family stress, and possible persistence into adolescence and adulthood. For a minority the outcome is antisocial behaviour, criminality and substance abuse. The multiplicity of aetiology, heterogeneity of presentations, changes over time, and intervention and range of possible treatments, make management complex and confusing. Approaches to diagnosis and treatment are not equally validated and support is compromised by the lack of, or long waiting lists for, support services. This context emphasises the use of medication which can have powerful short-term benefits for disrupted behaviour and performance. The need for medication and its effectiveness is relative to the nature and severity of problems and the use of other interventions. A multimodal approach, especially with educational and behavioural supports, should be used if available. Although medication is the most effective short-term treatment for the disruptive behaviours of ADHD, other approaches may add to the success of medication and be essential if medication is ineffective. Comprehensive assessment and management is emphasised in managing ADHD. Day-to-day support for the vulnerable individual at home, and in other settings, should be provided. Management is, however, complex and time consuming and requires collaboration. Medication, whilst the best validated of the various interventions, is likely to be better accepted when accompanied by advice regarding other supports. Referral to supports should be vigorously pursued, though other services may be scanty (Hazell, McDowell, Walton et al 1996). The prescribing of medication is exclusive to the medical practitioner, but few can provide intensive, prolonged behavioural and emotional management. ADHD usually requires, among other services, psychological or psychiatric support. North American practice and research dominates paediatric psychopharmacy, particularly in ADHD, reflecting the prevalence of disruptive behaviours responding to medication. The stimulants are methylphenidate, which is most studied, and dexamphetamine, which is less so, and other medications are used (Werry 1994). A very recent extensive review by Spencer, Biederman, Wilens et al (1996) describes medication in the treatment of ADHD for children and adults. This refers to 155 controlled studies in over 5700 individuals documenting the efficacy of stimulant medications. Other authors have stated that stimulants are safe and effective drugs (Gadow 1992) and have few side-effects when used in children under proper medical supervision (Werry 1988). The place of medication may decrease in importance as other vulnerabilities in the child or the childâs environment are dealt with, and as the child moves away from the threshold of the disorder. Indeed, stimulant medications have been shown to have similar types of effect in children with diagnosed ADHD and individuals regarded as normal controls (Peloquin and Klorman 1986; Rapoport, Buschsbaum and Monte 1980; Rapoport, Buschsbaum and Zahn 1978). These results emphasise that the diagnosis of ADHD cannot be determined by a positive response to medication. Non-stimulant medicationsThere are few studies of ADHD management with medications other than stimulants, with useful reviews by Green (1992) and Spencer, Biederman, Wilens et al (1996). There is little quality of evidence rating II or III-1 (see Introduction, p2). The more recent references quoted in Table 1 report on open trials or case reports to allow practitioners to pursue what information does exist, even if it currently carries a lower level of evidence. If medications other than stimulants appear to be indicated, further expert opinion should be considered, particularly if multiple medications are used. The demonstrated efficacy and safety of stimulants for ADHD and its co-morbid conditions encourage their use over other medications that have been less extensively studied. Nevertheless, the prescription of ADHD stimulant medication is restricted under ‘drugs and poisons’ legislation across the States and Territories as a ‘drug of addiction’. Follow-up studies, however, show no evidence for addiction when stimulants are prescribed appropriately for ADHD (Klein and Mannuzza 1991). Practitioners can prescribe without restriction other medications, which may have partial effects, no rigorously proven benefits in ADHD and more serious side-effects. Lack of precision in titration of dose and lack of immediate effect of nonstimulant drugs can encourage arbitrary use, imprecise diagnosis of ADHD, risk of side-effects and can confuse the wider public and professionals about management of ADHD. Mechanisms that are in place for monitoring the use of stimulants have no jurisdiction over these other medications. They may be useful, however, for children for whom stimulants are ineffective, have unacceptable side-effects, or who have significant co-morbid anxiety, depression or tic disorder or may potentially abuse prescribed stimulants. Use of nonstimulant medications should be used with caution, with knowledge of recent literature and up-to-date clinical advice, particularly for newly available medications and those used in combination. The artificial nature of diagnostic boundaries means that professionals may differ in how they perceive, interpret and categorise the same qualities and dimensions in one child, and may reach different diagnoses and, as a result, prescribe different medication. At present there are no reliable criteria for widespread clinical use that can identify groups and individuals with different aetiology, target symptoms and responses. Some neuroimaging and neurophysiological assessment tools may have this potential, but their usefulness has yet to be proven in rigorous research, let alone translated into widespread clinical practice. Australian work has suggested in a single-dose study that auditory event-related potentials can predict methylphenidate response in 81 per cent of individuals (Young, Perros, Price et al 1995). Suffin and Emory (1995) claim robust correlations between neurometric quantitative electroencephalogram (QEEG) subgroups, clinical outcome and response to stimulants, antidepressants and anticonvulsants. However, these techniques are largely confined to research studies and their validity and specificity is vigorously debated (Chabot, Merkin, Wood et al 1996; Duffy, Hughes, Miranda et al 1994; Levy and Ward 1995). Most practitioners do not have experience and training in the use and interpretation of such methods and they do not form part of the primary management of ADHD.
|
