|
Medication Treatment For ADHD: Controversy AboundsMedicating Children: ADHD and Pediatric Mental Healthby Rick Mayes, Catherine Bagwell, and Jennifer Erkulwater
Between 1987 and 1996 the use of medication treatments for pediatric attention deficit hyperactivity disorder (ADHD) increased fourfold, from 0.6 percent to 2.4 percent. Treatment rates have since plateaued, but stimulants are still the most-prescribed psychotropic drug for children.1 Although theories regarding the cause of these increases abound, what has not surfaced is a clear consensus on whether increases in the diagnosis and treatment of childhood ADHD indicate success in reducing the symptoms of an important disabling disorder, leading to improved outcomes for sick children, or society’s failing of America’s youth. In Medicating Children, Rick Mayes and coauthors summarize the controversies surrounding ADHD diagnosis and treatment by addressing three relevant questions. First, the authors examine possible explanations for such rapid increases in stimulant medication use. Proponents of ADHD medication treatment suggest that these increases can be attributed to dissemination of evidence on the effectiveness of stimulants in treating children. Others argue that changes in public programs, including the Individuals with Disabilities Education Act (IDEA) (the federal disability program) and public health insurance programs have created incentives that encourage diagnosis and medication treatment. Finally, possible cultural changes, including declines in the quality of the U.S. educational system, changes in family demographics, and the neglect of the needs of boys in an increasingly regimented society, have also been widely cited in the news media as leading to inappropriate overdiagnosis and treatment of ADHD. Second, the authors consider the increase in medication treatment of ADHD in the context of the wider use of psychotropic medications for children generally. As with other mental disorders, there is no objective test to determine diagnosis, and the difference between the presence and absence of disorder may be a matter of degree. The authors highlight that the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III), greatly expanded diagnoses of childhood disorders more generally, reflecting a greater recognition of the importance of children’s health. Finally, Mayes and colleagues consider why this disease has been so controversial. They note that an important distinction between ADHD and other diagnoses is the strong educational aspect of ADHD: the first diagnosis is often made by a teacher. The authors observe that "where the boundary between ADHD and typical childhood behavior is located is ultimately a political and social choice, not a scientific one" (p. 172). The authors have done a great service to parents and policymakers, as well as university faculty teaching mental health policy, by presenting a reasoned, thorough, and unbiased summary of the voluminous literature on ADHD diagnosis and treatment. By combining the talents of a public policy analyst, a researcher trained in child clinical psychology, and a political scientist, the authors effectively summarize and integrate the clinical and social science literatures. Moreover, they cover the "backstory" of ADHD thoroughly, which contributes in important ways to current debates in U.S. mental health policy. In reviewing this history, the authors highlight and reflect on similarities that ADHD shares with other mental disorders, including the growing recognition of mental illness as a biological disorder, the availability of evidence-based treatment, and reductions in stigma. Yet while the authors emphasize the challenges to understanding increases in ADHD diagnosis and treatment, they offer few suggestions on how to overcome these challenges. There is little insight into which factors the authors believe are most important. Instead, they conclude that all have contributed in some way. As to the consequences, the authors fail to take a clear stand on whether they believe that ADHD is overdiagnosed. Also, because they do not consider actionable policy recommendations, the reader is left with the feeling that we are never likely to agree on the best course of action for children with ADHD. This is problematic, because the debate over ADHD medication treatment shows no sign of abating. Until recently, the scientific evidence concerning the effectiveness of medication treatment has been uncontroversial. Results from the National Institute of Mental Health (NIMH)–funded Multimodal Treatment Study of Children with ADHD (MTA) clearly indicated that stimulants are an effective short-term treatment for ADHD, with medication resulting in better symptomatic relief than treatment with just behavioral therapy or usual care at fourteen months. These results have been available since 1999. The recent publication of the eight-year follow-up to the MTA trial has cast some doubt on the long-term effectiveness of stimulant use, with no long-term differences found between the groups originally randomized to medication treatment versus other groups.2 Some researchers have cited these results to support the view that medications are not effective over the long term, while others have emphasized that some subgroups do continue to improve or that the study design does not allow one to draw definitive conclusions about long-term effectiveness.3 In addition, new data on the possible risks of pediatric stimulant use have been widely covered in the popular press. These include smaller increases in height for children with ADHD who take medication compared to those who do not. Based on a small number of cases, an association between stimulant use and sudden death has also been suggested. In February 2006 a Drug Safety and Risk Management Advisory Committee voted to recommend that the Food and Drug Administration (FDA) place a black-box warning (BBW) on medications used in the treatment of ADHD. In March 2006 a second committee recommended including warnings in new labeling and failed to recommend a BBW; the FDA subsequently determined that the BBW was unnecessary. In our increasingly consumer-driven medical care system, parents rely on the popular media for information when making decisions about whether and how to treat children with ADHD. These sources may fail to prepare them adequately to interpret the extensive information on this topic. Thus, this book is a must-read for clinicians, parents, and policymakers with pressing questions about ADHD.
Susan Busch (susan.busch{at}yale.edu) is an associate professor of health policy at the Yale School of Public Health in New Haven, Connecticut. NOTES
| |||||||||||||||||||||
