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Long-term ADHD Treatment

ADHD medication is frequently in the news. Often the impression is given that the medication treatment is the only way to go, or that it is a risky way to go. Taking a few steps back to get a clearer overview, we see that neither side has the answer. ADHD is a complex and controversial subject.

Medication is clearly a part of the treatment for most, but not all people with ADHD. Even for those who are helped by ADHD medication, it is not the whole treatment. One thing all experts agree on is that medication cannot cure ADHD.

On a day-to-day basis, ADHD medicines last only hours, and need to be tailed off before bedtime. In the long term, studies have shown, the initial clinical benefits are lost as many patients fail to keep their medication treatment or see their doctor regularly to adjust doses.

The largest and longest treatment study on ADHD so far, is the Multimodal Treatment Study of Children with ADHD, which started in the 1990s. The latest follow-up report of the study was recently published on the Journal of the American Academy of Child and Adolescent Psychiatry’s Web site in March 2009. The study followed 436 children and adolescents over eight years (75% of the original 579 seven to nine- year-olds are still in the study). The children and adolescents in the study represent different ages, developmental stages, levels of impairment, co-occurring disorders, and family resources.

The study compared different treatment programs. The children were divided into four groups. The first received conventional treatment within their community, which involve the entire family and key individuals in the child’s life such as school personnel and treatment from their own doctors. The second group received intensive behavioral therapy including cognitive behavioral therapy, parenting training, and social skills training in managing symptoms associated with ADHD. The third group were on a managed medication treatment, and the fourth group was on a combined medication and behavioral therapy treatment.

The group, which improved most after 14 months, was the fourth, combined treatment group. What was significant with these children was that they improved better than the others in social skills and in their relationships with their parents. At that point all the children went back to community based treatment.

Two years later a follow-up assessment showed that the improvements did not last and the groups were about the same in their assessments.

The latest report is at the eight-year follow-up. The assessments of children, now in their mid teens, showed that there was no correlation between the treatment eight years ago and their present ADHD symptoms, behavioral and functional assessments, academic performance, and social functioning.

20% of the teens had not medicated during any assessment period. Only 17% had remained on medication throughout the 8-year period. Of the children who took ADHD medicines in the initial phase, 62% had stopped at some point afterwards. Medication use in the previous year was not associated with significantly better functioning at the eight-year assessment. Among the patients who were medicated during the intervention phase eight years earlier, 62 percent had stopped taking ADHD medications in subsequent years, which may in part account for the loss of treatment benefits seen in the 14-month analyses.

"These findings are not really surprising," said Brooke Molina, Ph.D., an associate professor of psychiatry at the University of Pittsburgh Medical Center, in an interview with Psychiatric News. She was the lead author of the eight-year study.

One of the important messages from the study, she explained, is "the many differences between children with and without ADHD. It used to be believed that these children could outgrow the behavioral and developmental symptoms in their adolescence. The study show that, as a group, they still lag behind their peers."

"The message is not that treatments do not work. Rather, the study showed that a one-year intensive therapy in childhood does not make much difference in the long run compared with less-intensive treatment. ADHD is a chronic disorder that cannot be cured by one-year intensive treatment," she said. In the context of long-term adverse effects of stimulant use, such as growth suppression, "medications are not the panacea for the long-term health of these children. We need to develop more treatment options with long-term effectiveness and palatability with teens."

David Fassler, clinical professor of psychiatry at the University of Vermont School of Medicine, and a child psychiatrist echoed this interpretation. "The study results should be interpreted with caution. Treatment conditions were no longer randomized in most of the follow-up period, and the dropout rate at eight years should be taken into consideration.” He also noted that the findings are generally consistent with clinical experience.

"For many children with ADHD, treatment will vary over time and often include periods on and off medication, as well as working with the child, parents, and, ideally, the school," said David Fassler. "Ultimately, treatment is most effective when it's closely monitored and individualized to the needs of the child and family."

In addition, Molina recommended that parents and clinicians regularly re-examine the effects of medication therapy in children with ADHD and carefully consider whether to continue it. "Some children may continue to derive benefits from treatment," she said. "However, it is extremely important that we do not automatically leave patients on medications for years without re-evaluation."

Robert Hendren, the President of the American Academy of Child and Adolescent Psychiatry said, “This study has different implications for different children and adolescents. It’s incumbent on physicians to help parents understand how the research affects the individual patient and to recommend a treatment approach created for the unique child.”

The treatment and other support needs to be planned around the child and the child’s responses to the treatment. Everybody is different and we need to keep in mind that it is our child or us or our spouse and not a statistical average. Unfortunately it is often difficult to find a doctor with expertise in ADHD, therefore it is important that we are knowledgeable on the subject, so that we can help doctor be our guide.

Combined treatment involves a flexible and inventive attitude besides medication, which can benefit mostly in the academic area, the ADHD support structure should include behavioral therapy, school-based accommodations, alternative therapies such as Omega-3 fatty acids, and coaching. There is usually not one universal cure, but a wise balance of support. Coaching is very helpful both to parent and child, as well as adult ADDers and guiding the family inunderstanding ADHD and to give the needed support. ADHD can be a blessing as there are many successful ADHD personalities in the business world, science and the arts.

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