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Maximizing the Benefits of Stimulant Medication Treatment for Children with AD/HD
David Rabiner, Ph.D.
Senior Research Scientist
Duke University
When a child is diagnosed with AD/HD, an important decision that parents
confront is whether to include medication as part of their child's overall
treatment plan. Although many factors are involved in this decision, medication
treatment is frequently recommended because it currently has the most
substantial research support as an effective treatment for AD/HD. By 1996, 161
randomized controlled trials involving thousands of individuals with AD/HD
across a wide age range had been published, and improvements were reported to
occur in between 65 and 75% of those receiving stimulant medication. Although
many of these studies were short-term trials lasting fewer than 12 weeks,
results from the Multimodal Treatment Study of AD/HD (i.e. MTA study) indicated
that benefits of carefully conducted medication treatment persist over longer
time periods, as positive outcomes were reported after children were followed
for 14 months.
Although the benefits of medication treatment are well documented, results from
carefully conducted research may overestimate its value to children treated in
regular community settings. In the MTA study, children receiving medication
treatment through the study - whether alone or in combination with intensive
behavioral therapy - experienced greater reductions in AD/HD symptoms than
children treated with medication by community physicians. For example, 68% of
children receiving combined treatment (i.e. medication and behavior therapy) and
56% of children receiving medication treatment alone had ratings of AD/HD and
ODD (i.e. oppositional defiant disorder) symptoms after 14 months that fell
within the normal range. In contrast, only 25% of community treated children
treated - two-thirds of whom received medication - showed normalized levels of
symptoms. (You can read a review of this study here.) Approximately 90% of
children receiving medication in the MTA study no longer met full diagnostic
criteria for AD/HD. Results from a recent study of children with AD/HD treated
with medication by community physicians, however, found that that almost 40%
continued to meet full AD/HD diagnostic criteria. Finally, in another recent
report, there was no indication that community-based treatment improved the
educational outcomes for children AD/HD.
A reasonable conclusion to draw from this evidence is that although medication
treatment can effectively manage AD/HD symptoms for many children, the benefits
provided often fall short of what is possible. For this reason, it is important
to understand why children treated in research studies often do better than
children receiving the same medication in the community. This knowledge can help
parents maximize the benefits of medication treatment for their child, should
the decision to try medication be made in consultation with their child's health
care provider. Thus, the focus of this article will be on guidelines for
maximizing the benefits of medication treatment once this decision has been
made, and not on considerations involved in this decision. Such decisions often
involve a multitude of factors and are best made in consultation with an
experienced health care professional.
Lessons from the MTA Study
What practices are likely to increase the gains associated with medication
treatment? An examination of medication treatment procedures used in the MTA
study provides valuable information on this question. Key elements of these
procedures, and how they are likely to differ from what typical practice, are
highlighted below.
* Children received an initial trial in which they were tested on 3 different
doses of stimulant medication and a placebo. Parents and teachers completed
standardized ratings of children's behavior and side effects on the different
doses to help insure that medication provided a significant benefit (i.e. the
child did better on medication than on placebo) and to determine the optimal
starting dose for each child. Systematic monitoring of children's response to a
full range of doses, although recommended in the treatment guidelines recently
published by the American Academy of Pediatrics, may often be neglected in
community practice setting. As a result, many children are likely to start
treatment on a non-optimal dose.
* For those children for whom the initial stimulant was not effective, further
testing using other stimulants was initiated. Thus, rather than giving up on
stimulant medication if initial results were disappointing, testing was
continued using other medications, and an effective medication was eventually
found for the vast majority of children. In community settings, it may be more
common for medication to be discontinued if initial results are not positive, or
to switch to another class of medication before trying other stimulants.
* Once an effective medication was found, MTA treated children received 3 doses
per day to provide full day coverage. Children treated in the community with
medication received an average of about 2 doses/day, and, on average, received a
smaller total daily dose. Because study treated children experienced greater
reductions in AD/HD symptoms, children receiving medication treatment in
community settings may often be maintained on doses that are not sufficient to
provide maximal benefit. (Note: The initial stimulant used in the MTA study was
methylphenidate, the generic form of Ritalin. Since the MTA study was conducted,
several longer acting stimulants have become available - e.g. Concerta,
Adderal-XR, Metadate, Ritalin- LA. These medications may be preferable in many
instances because they eliminate the need for administration during the school
day, which often
poses a variety of problems.)
* Once the initial medication and starting dose was determined, ongoing
treatment effectiveness was monitored via monthly follow up visits and phone
contacts with children's teachers. In community settings, ongoing treatment
monitoring is typically far less intensive.
Translating these Lessons into Practice
Although there were other differences between study- and community-treated
children, those discussed above certainly seem to be among the most important.
Because the procedures used in the MTA study resulted in better child outcomes,
it is important that parents try to make sure that their child's treatment is
consistent with these procedures. Although the specifics of some MTA medication
treatment procedures would be difficult to replicate exactly in community
settings (e.g. the initial placebo-controlled trial involving daily dose changes
and daily teacher and parent behavior ratings), the principals underlying these
procedures are not. In fact, guidelines for improving AD/HD medication treatment
in community settings that draw on MTA results have been published recently by
the American Academy of Pediatrics, the American Academy of Child and Adolescent
Psychiatry, and the Texas Consensus Conference Panel. Key elements of these
guidelines are synthesized below.
Guideline #1- When initiating medication treatment, be sure that your child is
tested on a full range of doses.
The optimum stimulant dosages for a child are not weight dependent and it is not
possible to predict in advance what the best dose -- or most effective stimulant
-- will be for an individual child. Clinicians should begin with a low dose and
gradually increase it across the full range of recommended dosages to determine
the best fit for each child. The critical reason for this is that the first dose
to yield beneficial effects may not be the best dose to optimize a child's
functioning, and unless a child is tried on a full range of doses, it is quite
possible that the optimal starting dose will be missed.
Guideline # 2 - Before medication treatment is implemented, parents should
insist that a systematic procedure is in place to monitor the effectiveness of
the different doses being tested.
Determining the benefits of medication treatment need to be far more systematic
than anecdotal reports from a teacher that the child seems to be "doing
better". Treatment guidelines recently published by the American Academy of
Child and Adolescent Psychiatry recommend that standardized and validated
behavior rating scales, along with systematic procedures for evaluating side
effects, be used to determine whether medication was effective and to decide
upon the optimal starting dose. In addition to ratings of core AD/HD symptoms -
i.e. inattention and hyperactivity-impulsivity - it is important to obtain
information on the child's academic functioning, social relations, and ability/willingness to follow rules at home and school. This is important
because effective treatment for AD/HD should enhance children's functioning in
these key areas in addition to reducing core AD/HD symptoms. And, even when
medication is effective in reducing core symptoms, residual difficulties in
important functional areas can still remain. When this occurs, additional
treatments that specifically target these residual difficulties need to be
incorporated. Without a procedure for assessing outcomes of medication treatment
in multiple domains, the information needed to make these important treatment
decisions will not be available.
Guideline #3 - If the initial stimulant medication tested is not effective,
alternative stimulants should be tried before giving up on medication, trying a
different class of medication, or combining other medications with a stimulant.
As noted in AAP treatment guidelines, children may respond favorably to one
stimulant, but not another. And, which stimulant or dose will be most effective
for a particular child is currently impossible to predict. For this reason, the
guidelines recommend that 2-3 stimulant medications be tested across a full
range of doses before non-stimulant medications be considered.
Results from the MTA study suggest that when this procedure is followed, the
vast majority of children with AD/HD will obtain effective AD/HD symptom
management with one of the stimulants, and using non-stimulant medications (e.g.
clonodine, antidepressants, etc.) or multiple medications will rarely be
necessary. In fact, less than 2% of children receiving medication treatment in
the MTA study were on non-stimulant medications at the end of the study. Many
children treated in community settings, however, are prescribed non-stimulant
drugs or receive several medications simultaneously. For example, a recent
report indicates that almost of 25% of children who receive stimulant treatment
are also prescribed a second medication. This is concerning because research
supporting the safety and efficacy of combined pharmacotherapy for children with
AD/HD is sparse.
In the MTA study, there were certainly a higher percentage of community treated
children who received non-stimulants and/or multiple medications. And, because
outcomes for community treated children were poorer, there is little indication
that this is generally helpful or necessary. Although there may be specific
situations where non-stimulants or multiple medications are, these practices
seem to be outpacing any available research support, and parents who receive
such recommendations for their child should proceed cautiously.
Guideline #4 - After medication treatment has been initiated, it is critically
important to monitor its ongoing effectiveness so that any necessary treatment
adjustments can be made.
The importance of carefully and systematically monitoring the ongoing
effectiveness of medication treatment for AD/HD cannot be overestimated. In many
instances, although a child's symptoms may be managed well as treatment begins,
this can change significantly over time. In the absence of a careful procedure
for monitoring a child's ongoing functioning, treatment adjustments necessary to
maintain optimal symptom management may not occur and poorer outcomes are likely
to result.
The importance of carefully monitoring the ongoing effectiveness of medication
treatment was highlighted in a recent report from the MTA study. As discussed
above, medication treatment in the MTA study began with a careful procedure to
determine the optimal starting dose for each child. Monthly follow up visits,
including gathering direct information about the child's functioning from his/her teacher, were then used to determine whether this dose continued to be
effective, or whether adjustment to the child's medication treatment was
required.
* One might think that because such a careful procedure to determine the optimal
medication and dose for each child was employed, that adjustments would be
relatively rare. As indicated below, this was definitely not the case.
* Only 17% continued on the same medication and dosage throughout the entire
13-month maintenance period. The remaining children all experienced at least one
change in drug or dosage during this period.
* Three months into the maintenance period, 56% of children had already had
their medication or dosage changed. The average amount of time to the first dose
change was 4-5 months. Across the entire maintenance period, the average number
of changes required for each child was just over 2, but some children required
as many as 10 medication adjustments. Of the total medication changes made, 62%
involved increasing the dosage of the current medication, 31% involved
decreasing dosage, and only 7% involved changing medications entirely.
As these results illustrate, effective medication treatment for AD/HD goes far
beyond finding a medication and dose that provides initial benefits and simply
continuing that treatment uncritically over time. Even when this initial
treatment is determined in the most careful manner possible, it is likely that
adjustments will be required to maximize treatment benefits over time.
Unfortunately, this may rarely occur in community treatment. For example,
children who received community care in the MTA study averaged just over 2
follow up visits per year, rather than the monthly visits provided for study
treated children. And, it is unlikely that direct feedback from teachers was
routinely obtained. This difference in ongoing treatment monitoring, and the
adjustments to children's treatment that were made as a result, may be the
single most important reason that MTA treated children had superior outcomes.
Without careful monitoring of ongoing treatment effectiveness, information
needed to determine when treatment adjustments may be necessary will be lacking,
and the likelihood that medication treatment will provide the maximal benefits
will be reduced. (Note: Careful, ongoing treatment monitoring is not just
important for medication treatment, but for whatever treatment(s) a child is
receiving.) As a result, the child may receive sub-optimal medication treatment
over an extended period, and this can adversely impact functioning in a variety
of areas.
Parents can minimize this possibility for their child by insisting that there be
a plan to monitor the ongoing effectiveness of their child's treatment that is
implemented consistently. This monitoring plan should include attention to both
core AD/HD symptoms as well as key functional outcomes (e.g. academic
performance, peer relations, following class rules), and physicians should be
receiving this information from both parents and teachers. I have developed a
relatively simple monitoring system that provides one example of how to obtain
and interpret this important information from teachers. You can request this for
free by sending an email to:
monitor@helpforadd.com
When you send an email to this address, the information will be immediately sent
to the address your request originates from.
Summary
It is important to emphasize that the guidelines presented above are based on
current research regarding best practices for medication treatment. As new
research and new medications become available, best practice procedures may
change accordingly. For example, the first non-stimulant medication specifically
approved for treating AD/HD is expected to become available shortly, and
research on this medication may result in its being regarded as a viable
alternative to stimulants as a first line treatment. Regardless of what new
medications become available, the recommendation pertaining to ongoing and
systematic treatment monitoring should remain critical.
As noted above, the guidelines synthesized above have all been published
relatively recently, and one hopes that physicians will be incorporating these
recommendations into their regular practice patterns. In particular, because
primary care physicians treat the vast majority of children with AD/HD,
guidelines from the AAP have the potential to significantly enhance the quality
of care that many children receive. Because treatment guidelines may not be
adopted quickly, however, in many instances it will be up to parents and
non-physician health care providers to make sure that children's treatment is
consistent with current best practice guidelines. I hope this article has
provided information that can be of help in this critically important task.
This article first appeared in Attention Research
Update, a free newsletter that helps parents, professionals, and educators keep
informed about new research on ADHD. You can learn more about the newsletter by
visiting http://www.helpforadd.com
Rabiner, David. (2002). Maximizing the Benefits of Stimulant Medication
Treatment for Children with AD/HD. Attention Research Update. Volume 71,
November 2002. http://www.helpforadd.com/background.htm
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