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October 2, 2014

Clinical update on ADHD

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Photo by Burger/Phanie / Rex Features

Pat Kelly and Dara Gantly report on new treatments for attention deficit hyperactivity disorder (ADHD), the link with autism, and why we are still only recognising a very small proportion of those with the condition.

One-in-10 children with ADHD receive correct diagnosis

An internationally-renowned expert on ADHD and conduct disorders believes that while there has been a greater recognition of ADHD, clinicians are still only correctly diagnosing a fraction of such cases. Pat Kelly reports.

Dr David Coghill is a senior member of the European Network for Hyperkinetic Disorders (EUNETHYDIS) who has taken a leading role in the development of European guidelines for the assessment and management of ADHD and a programme to aid clinicians to implement these guidelines into practice.

He is also Associate Editor for the Journal of Child Psychology and Psychiatry and European Child and Adolescent Psychiatry and is the Senior Author of the Oxford Specialist Handbook on Child and Adolescent Psychiatry.

In addition, he is joint Lead for the Developmental Disorders Team within NHS Tayside Child and Adolescent Mental Health Services and has developed evidence-based clinical pathways for the assessment and management of ADHD that have been used as a template for other services around the world.
“In the past 10 years, there has been much more acceptance in general — both by the medical community and the general public — that medication can play an important part in the treatment of ADHD,” Dr Coghill told IMT.

Non-drug treatments
“One of the important pieces of clinical information that we now have is that for children with mild or moderate ADHD, we perhaps should be thinking of non-drug treatments as a first option, but for those with severe ADHD, non-pharmacological treatments are unlikely to be enough on their own.”

Dr Coghill pointed out that rather than there being an increase in incidence of ADHD in recent years, it is more accurate to say that there has been a heightened recognition of the condition among clinicians. “There has been a combination of an increase in both clinical skills and awareness among clinicians, but also greater awareness among the general population, such as among teachers, for example, and also among GPs.

“There is now a greater awareness that when a child has problems, ADHD may be one of the potential causes and there is a rise in the numbers of people being referred and a big increase in people’s recognition of what they are seeing when they do encounter ADHD.

“However, in the UK — and I believe this to be the case in Ireland also — we really only recognise a very small proportion of those who do have ADHD. Probably at best, we get one-in-five but the figure is more likely to be one-in-10 of these children who receive a correct diagnosis,” Dr Coghill suggested. “So even though there has been a big increase, ADHD is still very much under-recognised and under-treated.”

He pointed out that recognising and gauging the severity of the condition was key in this regard. “We recognise the severe cases, but with the less severe cases, people often say, ‘it’s a behavioural problem’, without actually wondering why the problem exists and what kind of problem it is.”

Specialist assessment
Dr Coghill advised: “For clinicians on first presentation, it is important, of course, to ask about symptoms such as over-activity, ability to concentrate and impulsiveness, but it is more important to establish whether these are occurring to the extent that they are interfering with everyday life. If this is the case, then specialist assessment is appropriate.”

In terms of the communication that is necessary between different clinicians and specialists along the care pathway, Dr Coghill commented: “There is always room to improve communication to improve outcomes. In the UK, as in Ireland, doctors are working under enormous pressure with time constraints and volume of work. But if we do not communicate well, we are not going to have the best level of care.”

New treatments
Dr Coghill explained that important new treatment options were in the pipeline for the treatment of ADHD. “The new medical prodrug treatments emerging are most promising,” he explained. “The real benefit is not that it is better than existing treatments, but that it is different. We know that the first-line existing treatment is effective, but is only effective in about seven out of every 10 people who try it,” said Dr Coghill. “Lisdexamfetamine [new treatment] is also effective in seven out of every 10, but it is a different seven. So with the two medications, we can go up from success in seven out of every 10, to around 19 out of 20, which is a real benefit for those children who do not respond [to previous treatment].”

However, he revealed that interesting non-pharmaceutical treatments were also evolving. “A treatment called neurofeedback [a treatment that involves real-time EEG displays to illustrate brain activity] is on the horizon,” Dr Coghill told IMT. “This can feed information from the brain back into the brain and it’s a completely painless, harmless option where the information is fed back to the brain.

“There is some indication that in the future, once we understand how to really focus that, it could be a really helpful treatment for ADHD. This is still at the experimental stage but there are indications that it works, but still needs to be honed to make it more effective.

“It’s not quite ready to put out there in the clinics yet but it is ‘in the mail’, as they say. So there a number of treatments on the horizon that make me really hopeful,” he concluded.

One-third with autism also have ADHD

In a study of the co-occurrence of attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) in early school-age children (four to eight years old), researchers at the Kennedy Krieger Institute in Baltimore, Maryland found that nearly one-third of children with ASD also have clinically significant ADHD symptoms.

Published in Autism: The International Journal and Practice (Epub ahead of print), the study also found that children with both ASD and ADHD were significantly more impaired on measures of cognitive, social and adaptive functioning compared to children with ASD only.

Photo by WestEnd61 / Rex Features

Distinct from existing research, the current study offers novel insights because most of the children entered the study as infants or toddlers, well before ADHD is typically diagnosed. Previous studies on the co-occurrence of ASD and ADHD are based on patients seeking care from clinics, making them biased towards having more multifaceted or severe impairments. By recruiting patients as infants or toddlers, the likelihood of bias in the current study is significantly reduced. “We are increasingly seeing that these two disorders co-occur and a greater understanding of how they relate to each other could ultimately improve outcomes and quality of life for this subset of children,” explained Dr Rebecca Landa, senior study author and director of the Center for Autism and Related Disorders at Kennedy Krieger. “The recent change to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) to remove the prohibition of a dual diagnosis of autism and ADHD is an important step forward.”

Participants in this prospective, longitudinal child development study included 162 children. Researchers divided the children into ASD and Non-ASD groups. The groups were further categorised by ADHD classification according to parent-reported symptoms of ADHD on the Hyperactivity and Attention Problems subscales of the Behavioural Assessment System for Children-Second Edition, a standard assessment specifically designed to identify the core symptoms of ADHD.

Results revealed that, out of 63 children with ASD in the study, 18 (29 per cent) were rated by their parents as having clinically significant symptoms of ADHD. Importantly, the age range for children in the study (four to eight) represented a younger and narrower sample than has been previously reported in published literature.

Researchers also found that early school-age children with co-occurrence of ASD and ADHD were significantly more impaired than children with only ASD on measures of cognitive and social functioning, as well as in the ability to function in everyday situations. They were also more likely to have significant cognitive delays (61 versus 25 per cent) and display more severe autism mannerisms, like stereotypic and repetitive behaviours. The study findings suggest that children with the combined presence of ADHD and ASD may need different treatment methods or intensities than those with ASD only in order to achieve better outcomes.

Dr Landa and her team recognise that this research supports the need for future prospective, longitudinal studies of attention, social, communication and cognitive functioning from the time that the first red flags of ASD are identified.

Autism, first published on June 5, 2013 as doi:10.1177/1362361312470494.

Stimulants not linked with later substance use risk

The treatment of attention-deficit/hyperactivity disorder (ADHD) with stimulant medication is not associated with either an increased or decreased risk of later substance use disorders, according to a meta-analysis published Online First by JAMA Psychiatry.

The use of medication, most often with stimulant medication (e.g. methylphenidate and mixed amphetamine salts), is a well-established treatment for ADHD and constitutes the first-line ADHD treatment in many clinical settings. The use of stimulant medication to treat ADHD remains controversial given concerns about its potential for abuse and possible role in sensitising patients to later substance problems, the authors write in the study background.

Kathryn L Humphreys, MA, EdM, of the University of California, Los Angeles, and colleagues examined the longitudinal association between treatment with stimulant medication during childhood for ADHD and later substance outcomes (i.e. lifetime substance use and substance abuse or dependence). The meta-analysis included studies with longitudinal designs in which medication treatment preceded the measurement of substance outcomes and that were published between January 1980 and February 2012. Odds ratios were obtained for lifetime use and abuse or dependence status for alcohol, cocaine, marijuana, nicotine, and nonspecific drugs for 2,565 participants from 15 different studies.

Separate random-effects analyses were conducted for each substance outcome. Results suggested comparable outcomes between children with and without medication treatment history for any substance use and abuse or dependence outcome across all substance types.

“These results provide an important update and suggest that treatment of attention-deficit/hyperactivity disorder with stimulant medication neither protects nor increases the risk of later substance use disorders,” the study concluded.

JAMA Psychiatry. Published online May 29, 2013. doi:10.1001/jamapsychiatry.2013.1273.