Less medication for ADHD is NICE message

Medication to treat behavioral symptoms associated with attention deficit/hyperactivity disorders should generally be a last resort, rarely the first, the retiring Head of Child and Adolescent Psychiatry at London’s Institute of Psychiatry has told clinicians in Exeter, UK.

Professor Eric Taylor was visiting the Peninsula Medical School to explain the outcome of his review for the UK National Institute of Clinical Excellence of the diagnosis and management of ADHD in children young people and adults.

Although the roots of the problem were largely genetic, its outward signs nevertheless had an impact on a child's immediate environment, he said.

A child's hyperactive behavior inevitably influenced the behavior of his her parents; they were likely to become "stressed out" or more hostile.

Similarly, a children's hyperactivity was likely to influence the the quality and strength of his or her relationship with peers. They might be unable to sustain reciprocal qualities required by strong, supportive friendships. They might be perceived as trouble makers or attract the damaging attention of other marginalized or negative peer groups.

Additionally, a hyperactive child’s behavior might influence how helpfully a classroom teacher responded. Restless, inattentive or disruptive children tended to receive a poorer standard of educational support.

And then there was a feedback loop to be reckoned with: hostile, stressed or negative views of a child (be they from parents, teachers or peers) were likely to make that child still less engaged and more severely ostracized.

Professor Taylor explained that he had been asked by NICE to recommend a wise response bearing these undercurrents in mind. Should society intervene directly with children through medication, or should energy be directed primarily towards the people who surrounded them, who were influenced by their behavior and in turn influenced behavioral development?

First and foremost, he said, ADHD should be recognized and be referable as a valid diagnosis. (Many still question the over-medicalization of what they regard as a behavioral disorder).

Second, that comprehensive assessment should become the normal basis of the response, informing the choice of intervention. including consideration of other symptoms or concurrent disorders such as conduct or oppositional-defiant disorder, as well as questions of cause and consequence. Too often schools were left out of the loop.

As for the NICE ADHD clinical guidelines themselves, he had recommended that they carry two key messages.

The first was that parents should be trained in the behavioral management of their children, as opposed to being routinely prescribed medication at the first sniff of inattentive or overactive behaviour.

He knew at the outset from the literature that teaching parents to manage and support their children was key. It nevertheless became startlingly obvious during the review; he had not predicted the strength of this approach.

So, following on, only in cases where a child was exhibiting severely disruptive forms of ADHD (a diagnosis which of course required rigorous assessment), or when the first line of parent-training intervention was ineffective, should medication be prescribed.

A number of effective forms of medication have been recommended: principally methylphenidate, atomoxetine and dexamfetamine.