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ADHD and medication

Medication and ADHD

As a pediatric psychologist, I am often asked the question: “Do you think medications are over-prescribed in children with ADHD?”  The question is a valid one and the numbers are pretty clear: the rates of stimulant medication prescriptions in children rose dramatically in the 1990s (from under 1% to 2.7%) and have been rising at a more modest rate ever since (Zuvekas & Vitiello, 2012).  The most recent rate of prescription in children and adolescents was 3.5% in 2008 (nimh.org).  This sounds like a lot but the truth is, this number is still lower than the 5% prevalence rate of ADHD (American Psychiatric Association, 2014).  What this suggests is that, while the majority of children with ADHD are on medication, there remains a large number who are not.

Medication and ADHD-What We Know:

What we know about stimulant medications is that they can be very effective in treating the coreADHD and medication symptoms of ADHD (inattention, distractibility, and hyperactivity).  What we also know about these medications, which is equally as important, is that they do not do much to impact the long-term course of ADHD (Molina, Hinshaw, Swanson, Arnold, Vitiello, Jensen, Epstein, Hoza, Hechtman, Abikoff, Elliott, Greenhill, Newcorn, Wells, Wigal, Severe, Gibbons, Hur, Houck, and the MTA Cooperate Group, 2009.)  Furthermore, for reasons that remain unclear, the maintenance of medication treatment over time is not well sustained despite the fact that we know ADHD tends to be a chronic condition (Molina et al., 2009 and American Psychiatric Association, 2014).

Other Treatment for ADHD:

This is where additional intervention approaches are vital to supporting children with ADHD and thus far the consensus is a prolonged multi-modal treatment approach that adapts as the child progresses through differing developmental stages.  Such approaches include behavior therapy with the child that focuses on specific skill building and self-awareness, parent training and psycho-education, teacher consultation, and classroom accommodations.  As children enter middle school, it can also be beneficial to spend time with an executive function tutor to begin to lay the foundation for keeping oneself organized, compensate for weaknesses, and feel a sense of control in their lives.

Medication is often an essential part of the treatment plan but to just treat the core symptoms of ADHD, without attention to the functional impairments it creates or the additional psychiatric conditions that often accompany it (learning disabilities, anxiety, depression, and conduct problem), would be remiss.

Click here to listen to Dr. Amy Wolok discuss ADHD and medication in an interview on Bloomberg radio.


ADHD

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Questions About Medication For Children

For many children, therapy or accommodations are not sufficient to support their needs.  It is often that these children will need child medicationpharmacological intervention to help improve their attentional regulation, impulse control, emotional regulation and/or behavioral self control. Parents should be honest with their pediatrician about medication as well as ask several questions about ensuring the best care.

Questions Parents Should Ask When Determining If Medication Is The Right Choice For Your Child:

  1. What are the side effects of the medication? All medications have side effects and it is important to be aware of what to possibly look out for.
  2. How long should the child be on medication?  It is important to ascertain if the medication is likely a temporarily solution or long-term.
  3. What therapies would be beneficial for the child to participate in while taking medication?  It is often that medication alone is not sufficient. Children will often benefit from specific therapies and interventions to help teach emotional and behavioral regulation.
  4. Who should I tell? My advice about medication is to always inform the academic staff as to when a child starts medication. Many times, the teacher would be able to have a greater watch over the child and monitor whether or not there are experiencing any negative side effects.

Medication is often warranted in a child’s treatment regime. It is always important for parents to ask good questions and work with a treatment team in order to ensure the best success of their child’s social and emotional development.

Diagnosing ADHD

Attention Deficit Hyperactivity Disorder (ADHD) is one of the most common neurological conditions that affects between 3 to 6 percent of school-aged boy jumping on couch children.  Children with this condition exhibit significant issues with their ability to pay attention to tasks, inhibit their impulses and/or regulate their behavior.   In order for the diagnosis to be made, one has to witness significant impairment in regards to attentional regulation and/or activity level within multiple settings.  This means that the child must exhibit the concerns within the home, school, after-school program, sports team, etc.  In reality, the diagnosis can be made by a pediatrician or health care provider that is able to ascertain levels of functioning in the various domains by observing behavior or collecting parent and teacher report forms.

In the Neuropsychology Department at North Shore Pediatric Therapy, we focus on a comprehensive evaluation of a child’s functioning, including cognitive functioning, academic achievement, attentional regulation, executive functioning and social/emotional functioning.  Now, if the diagnosis can be made by a parent and teacher report, one must ask why a comprehensive evaluation should be mandated.  The answer to this is that over 45% of children that have been diagnosed with ADHD meet clinical criteria for multiple neurodevelopmental conditions.  Children with ADHD often present learning disabilities, emotional concerns and deficits with social regulation.  Sole treatment of the inattention may improve attentional regulation; however, there are other unaddressed concerns that may still linger.

Research has continuously demonstrated that the most common treatment of ADHD is a combination of pharmacological intervention, behavioral therapy, parent training, and teacher education.  Pharmacological intervention consists of stimulant medications that help to improve the child’s ability to attend to tasks.  A recent research article, which was even reported in an October edition of the Chicago Tribune, indicated that the majority of children who have been diagnosed with ADHD and are prescribed medication report significant improvement within their daily lives.  In the past, the main identification of improvement within children with ADHD was based upon teacher report.  Parents can now feel comfortable when asking their child if medication is helping. Behavior therapy focuses on the modification of the child’s environment to improve the frequency and duration of positive, on-task behaviors while extinguishing negative behaviors.  Parent and teacher education has a primary intent on discussing expectations within the home and school settings as well as possible modifications to ensure success.


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ADHD Treatment Options

Attention Deficit Hyperactivity Disorder (ADHD) is one of the most common neurodevelopmental conditions. The United States Center for Disease Control has recently indicated that approximately ten percent of the school age population has been diagnosed with ADHD (CDC, 2010).ADHD

Typical symptoms that are exhibited in a child with ADHD include:

  • a lack of attention to details
  • difficulty following instructions
  • poor impulse control
  • hyperactivity
  • issues with regard to self-regulation

Research On ADHD Treatment:

The National Institute of Mental Health (NIMH) conducted the largest on-going research studies (MTA: Multimodal Treatment of Attention Deficit Hyperactivity Study) examining the efficacy of various treatment modalities for ADHD. This study consisted of over six hundred children who were diagnosed with ADHD.

Each child was assigned randomly to one of four treatment groups:

  • intensive medication management alone
  • intensive behavioral treatment alone
  • a combination of both
  • or routine community care which served as a control group

Outcomes Of The ADHD Study:

What the study found was that combination behavioral treatment and medication management were significantly superior to behavioral treatment alone in reducing symptoms of ADHD (Dec 1999, Archives of General Psychiatry). The results also highlighted that these improvements in functioning (with combination behavioral and medication therapy) lasted for upwards of 14 months. A final important finding from the study indicated that combination treatment (behavioral therapy and medication) was superior in treating other areas of daily functioning such as anxiety/depression, academic achievement, social skills, and family interactions in comparison to medication or behavior therapy alone.

ADHD treatment Options:

As the above study indicates, pharmacological intervention is oftentimes the first treatment of choice for a child with a diagnosis of ADHD. However, medication alone is not the only solution as was evident in the study. Behavior therapy, which focuses on teaching children appropriate self regulation skills by modifying the environment so that appropriate on-task behaviors are reinforced while negative, off-task behaviors are extinguished, is a vital component of a treatment plan. Many times parents do not want to go with medication as a primary treatment and would rather try behavioral therapy or working with a social worker to help develop socialization skills.

Many children with ADHD exhibit issues with their daily social functioning. It is important to realize that these social deficits are not because of a lack of inherent social skills but because of the impact that issues with attention to the social world and impulsivity have on their daily social interactions. The focus of the intervention then needs to be on how to change the child’s daily environment so that he or she is set up for success. Many times this will include modifications in the classroom setting to help improve on-task behaviors and self regulation. Another intervention that is often needed for a child with a diagnosis of ADHD is parent and teacher education. It is important to work with parents and teachers so that they can have a better grasp as to why they are observing particular behaviors.

In summary, the empirical research has indicated that a combination of pharmacological intervention and behavioral treatment is the number one intervention for a child with a diagnosis of ADHD. However, there are other options that are less invasive such as behavioral therapy in isolation, parent/teacher education, and/or social work support to help improve daily social interactions.

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