Marys Medicine

Adhd - a philosophical approach to assessment and management

ADHD There are few topics that engender more polarization of views than ADHD. This is not only within the general public but also amongst medical professionals. It is estimated from research that many medical professionals as well as the public generally get 90% of their information from the media. In addition, some of the medical papers published give information which is difficult to interpret or is presented in a way which gives a significant bias of view without considering alternative views based on the same information. Such has been the case with the MTA study.1,2,3 What is ADHD? ADHD is one condition which is well documented to be inherited as an autosomal dominant with a prevalence rate of around 5%. It is more common in boys (estimates M:F ratios vary from 3:1 – 6:1) and it is now appreciated that symptoms may vary significantly between the sexes at different ages. In addition it is estimated that in many populations only about half come to medical attention and many are never assessed medically and cope well with their lives. The current diagnostic coding of DSM IV is the best we have, its limitations being that it is simply a categorical listing of features agreed upon following much consultation. DSM V is in the process of being developed and will no doubt refine some aspects of what is understood to be ADHD in its different forms. The deficits evident in people with ADHD have been increasingly well documented over time and include deficiencies in working memory, short term memory and various aspects of executive function. (Executive function involves the ability to organise, prioritize philosophical and activate work, to focus and sustain focus shifting from one task to another, to regulate alertness, manage effort and processing speed, to manage and modulate emotions, to utilise working memory and approach to access past information as needed, and to monitor and regulate actions in time and space). These deficits pervade many day to day functions with the outcomes depending on the age and level of development of the affected individual. For example, the assessment incidence of motor vehicle accidents is about four times higher in untreated ADHD adolescents compared to their non affected peers. To make things more difficult to sort out, about 15% of people with ADHD will have a specific learning deficit. Other co-morbidities include anxiety (about 60%), depression (at least 20%), oppositional defiant disorder (45%), conduct disorder (around 35%) and substance and alcohol abuse (35%). So overall management about 70% of people with ADHD will have at least one co-morbidity. Treatments aimed at assisting with the underlying disorder may reduce later onset of 16 September 2008 LJ  708.indd      16 15/09/2008      9:35:49  AM By Dr Nick Woolfield, Director of Paediatrics, Caboolture Hospital, co- morbidities with substance and alcohol abuse benefit especially if anxiety is a significant Queensland reduced by as much as 85% by appropriate early co-morbidity. Care must be taken if it is to be used with SSRI medication and this is not a combination I use often. (dose of SSRI and/or atomoxetine How can you approach this with a needs to be lower).
Depression and anxiety are not uncommon My approach is to see this condition as one associated issues and can be managed in their manifestation of generic sin (Romans 3:23), own right with appropriate medications, usually i.e. like any other medical condition manifest in antidepressants. Other strategies may avoid the our imperfect world. As a clinician redeemed by requirement for medications. In previous times grace, I approach this with a framework of grace tricyclic antidepressants were endeavouring to demonstrate this in line with widely used in combination with "The incidence Isaiah 61:1. From this approach, my aim is to get stimulants and depending on the children as well assessed as possible and this of motor vehicle individual preferences are still will usually require a psychometric assessment used by many. They have a broad accidents is about and often a speech language assessment. In spectrum of neurotransmitter action addition, information from key players in the child's and may enhance some aspects of four times higher life is essential to gain a clear picture of what concentration as well as stabilise is happening. Hearing and vision checks are of in untreated ADHD value, and are often done prior to referral. From adolescents my perspective, the importance of getting the On an individual basis, unwanted assessments done cannot be underestimated. side effects of medications compared to their This elucidates specific learning deficits, and can frequently mean that changes in assist in defining areas of functional strengths non affected medications are required, and what and weaknesses. This becomes important in works well in one may not work addressing strategies to assist the child in working in another. Part of the craft of the towards improved outcomes, working out a plan clinician is to work out which medications work best of management across different life domains, with for an individual. Sometimes you hit the jackpot consistency and appropriate aids to assist the child on the first regimen; more often adjustments are to function as close to his peers as possible.
What is the place of medication? What else is involved besides medication? The well documented deficits in executive The remaining part of management is to assist function, in working and short term memory are children to develop appropriate social skills so as major impediments to daily function and are to develop as close to their peers as is reasonably deficits of primarily frontal lobe function. The possible. For those who have any specific learning stimulant medications (dexamphetamine and deficits additional assistance is often needed. If methylphenidate) which are primarily dopaminergic they have a deficit with verbal processing then to in their action, improve both of these areas have instructions in writing will often overcome of functional deficit. The dose required varies this deficit, or be an aid to assist them to function significantly from one individual to another and most closer to their peers. Although there is often will respond to doses around one tablet per 10 kg significant improvement in function on medication, of body weight (0.5 mg/kg for dexamphetamine there is usually the need to ensure that structure and 1 mg/kg for methylphenidate). I usually start is developed so as to optimise outcomes. Many on a dose much lower and build the dose up over children have been picked on and bullied because about two weeks to this as a maximum with doses of their social ineptitude and avoidance of such eventually being given after breakfast and lunch. situations and development of other networks which Neither has a long half life, and their short duration promote more acceptable developmental outcomes of action has led to the development of long acting is important.
preparations of methylphenidate of which several are available in this country on the Pharmaceutical But what about bad behaviour? Isn't using Benefits Scheme. In children who respond and the term ADHD just an excuse? can take the long- acting preparations this usually avoids the need for them to take medication at I think one of the most confusing things for many school. This can be immensely beneficial for the people is the dominance of the behavioural issues child. Other benefits of stimulant medications, apart in many of those with this condition where the from improved academic and social functioning, defect is one of concentration, working memory include better fine and gross motor function.
and executive function. Atomoxetine (Strattera) is a noradrenergic With respect to this issue, there are three main medication and is an alternative to stimulants points to be made. Firstly, there are many children but is not as successful in treating the deficits of with ADHD who show excellent behaviour. concentration. However, it is often successful in Secondly, it is necessary to acknowledge decreasing hyperactivity even if the benefits on that managing their behaviour can be a much concentration are not so dramatic. In combination bigger difficulty for many children with ADHD with stimulants there is often significant additional than for unaffected children. They need more LJ  708.indd      17 15/09/2008      9:36:23  AM ADHT: a philosophical approach to assessment and management encouragement and persistence on the part of In our situation the funding is through existing caregivers. But finally, stealing remains stealing; resources although some new monies have been aggressive physical and verbal behaviours are found to assist the process.
similarly unacceptable. Taking the approach of grace is one of the key issues that we as redeemed Wraparound incorporates many Biblical principles. It physicians need to take in working with such highlights the fact that the problems of the children belong to the child and the family and it makes no excuses. It aims to involve the families in the development of the plans of management. It also takes a zero blame approach; in other words it defines the behaviours that need changing. The most common diagnosis of the 20 plus children who have been assessed and managed through this process to date is ADHD with co-morbidities, usually of conduct disorder and oppositional defiant disorder and quite commonly with anxieties as well. An Example of Management: As part of the planned approach to these children, The Wraparound Programme most (17 of 29) are now fully reintegrated within Since early last year I have been involved in implementing their educational process and with substantial an approach to management of high needs children known improvements in social functioning as well, and as Wraparound.6,7,8,9,10 This was initiated locally by one most are on medications which have been adjusted primary school principal with the subsequent support of other according to response. principals. Education Queensland has assisted by funding an administration officer to assist with the coordination Outcomes following multi-professional input in of the program, which is aimed at the most behaviourally assessment and the planning process have on challenging children in these schools. The Wraparound occasions seemed nothing short of miraculous. For Process is one which evolved in the USA over about 20 example, one family now has a social life again after years and has 8 principles which include (www.rtc.pdx.edu/ not having gone out as a family for nearly six years, with their son now functioning nearly at the level of his peers in his final year of primary schooling. • Parents and/or child must be involved at each step of the This involvement with the family at each stage assessment and planning is Community based – it occurs acknowledging that we are only there to support where the families live.
them towards mutually agreed goals has been important. With many of the children (top 1 – 3% of • Services and supports agreed on through the planning most difficult children at schools) antagonism has process are individualised according the strengths and already developed between parents and education needs of each family (needs driven, not service driven) professionals and has had to be addressed through this process. To date I have usually chaired the • Plans must be culturally competent – the values, planning meetings. Plans developed across life strengths, preferences and social and racial make up of domains are implemented and then reviewed. If the family must be included in the plans.
the outcomes are not achieved then the plans • Family must be included in the development of the plan are revised. It has also been my job as part of at every point – they must have ownership of the plan.
this process to talk to school professionals whose mode of operation has been unsupportive of the • Access to flexible non categorical funding is needed to assessment and implementation process. Some support the plan.
people find this way of working challenges their professional ways and find it uncomfortable. I am • Interagency collaboration and coordination is needed to reminded that Jesus often dealt with people whose implement the plans and the plan must be acceptable to ways of working were not in line with the way he the community at large.
saw things (Jn 8:6-11). The outcome of this process for many children so far, has been much better than • Services must be unconditional – if the family's needs the previous ways of management. We would like change or some aspect of behaviour is difficult, the child/ to expand but this will require more funds to provide family is not abandoned by the service team –services more personnel to train and be involved. It is time are changed.
consuming but the outcomes more than justify this. Taking the time to work with such children and their • Finally, outcomes must be measured.
families is essential to achieving the outcomes.
In addition a couple of other issues are highlighted: I take a similar approach to children with ADHD who • The approach must be team driven involving the family, are not part of Wraparound. Defining unacceptable child, natural supports, agencies and community services behaviours and the outcomes of those behaviours working together to develop, implement and evaluate the is important. Actions have consequences, and individualised service plan.
taking ownership of such behaviours is important to success. In children with ADHD with a lack • Wraparound plans must include a balance of formal and of executive function this is often difficult until informal community based and family resources.
medications allow these deficits to be less evident. In families where one or other parent has the 18 September 2008 LJ  708.indd      18 15/09/2008      9:36:23  AM condition, there may already be some poor family "It is challenging for function. Drug and alcohol abuse and domestic 1. The MTA Cooperative Group A 14-
violence are not uncommon and need appropriate month randomised clinical trial of professionals who intervention. If it appears that one parent or other is treatment strategies for attention-deficit/hyperactivity disorder. Arch see these children affected then I will usually recommend that they see Gen Psychiatry 1999; 56:1073- their GP for assessment or referral for assessment.
and families to take The behavioural issues commonly associated 2. The MTA Cooperative Group
a gracious approach, Moderators and mediators of with Asperger's Disorder (in DSM IV under Autism treatment response for children grouping) can cause major social impact on the with attention-deficit/hyperactivity to be supportive child and the family. My approach, as with ADHD, disorder. Arch Gen Psychiatry 1999; 56:1088-1096 and flexible in is not to excuse behaviours as part of this condition but make it clear that it is the responsibility of 3. Carey WB (commentary) What their approach and the Multimodal Treatment Study
the child (and family). Strategies need to be put of Children with Attention-Deficit/ in place to minimise adverse outcomes as a to involve other Hyperactivity Disorder Did and result of the deficits in social interaction or the Did Not Say about the Use of supports as needed to obsessive behaviours. School based strategies Methylphenidate for Attention Deficits PEDIATRICS 2000. 105(4) may be essential to avoid bullying, and alternative 2000, pp. 863-864 achieve the desired placements or activities that interest the child may 4. Attention Deficit Hyperactivity be employed to assist with their social development. Disorder in Child and Adolescents With some individuals this may need to be very in NSW – 2007 Final report of specific. Longer term goals to assist with the special review, Clinical Excellence Commission http://www.cec.
development of social independence are part of the plan and sometimes achieving full social 5. Biederman J, Wilens T, Mick E, Spencer T, and Farone SV: independence is not possible.
Pharmacotherapy for attention deficit/hyperactivity disorder reduces risk for substance use disorder. PEDIATRICS 1999:104:e20 In summary, ADHD and associated conditions can be very challenging to assess and to treat. 6. Burchard JD, Bruns EJ, & Burchard SN (2002). The Being able to see that these conditions, like other wraparound approach. In Community treatment for youth: Evidence-based interventions for severe emotional and conditions, are because of sin in the world from behavioral disorders. Edited by Burns BJ, Hoagwood K. the fall of Adam, is essential in being able to New York, Oxford University Press. approach it like other conditions, aiming to get 7. Burns BJ, Goldman SK (Eds) (1999). Promising practices proper assessments (define the condition as well in wraparound for children with severe emotional disorders as possible and exclude other conditions) and then and their families. Systems of care: Promising practices in children's mental health, 1998 series: Volume IV. Washington, work with the individual and family towards mutually DC, Center for Effective Collaboration and Practice, American agreed goals which are appropriate for the age and Institutes for Research. sex of the child. The fact that other family members 8. Eber L (2003). The Art and Science of Wraparound. may be affected may also complicate the situation Bloomington, IN: Forum on Education at Indiana University. but nonetheless these families need the support 9. Eber L (2005). Wraparound: Description and Case Example. and assistance to enable changes to be In Sugai G & Horner R (2005) Ed., Encyclopedia of Behavior made which align to a biblical way Modification and Cognitive Behavior Therapy: Educational of life with the improved outcomes Applications. 1601-1605. Thousand Oaks: Sage. that come as a result of this. It is 10. Eber L, Nelson CM & Miles P (1997). School- challenging for professionals who based wraparound for students with emotional and see these children and families to behavioral challenges. Exceptional Children, 63(4), 539-555. take a gracious approach, to be supportive and flexible in their 11. Howard M, Schachter Ba' Pham, Jim King , Stephanie approach and to involve other Langford and David Moher supports as needed to achieve (2001) How efficacious the desired outcomes. It is and safe is short-acting clear that many professionals methylphenidate for the treatment of attention-deficit have an aversion to utilising disorder in children and stimulant medication for various adolescents? A meta-analysis. reasons. The main body of Canadian Medical Association Journal; 165 (11):1475 – 1488 the literature supports the improved outcomes seen with 12. Posner MI, Rothbart MK, (2007) early management and use of Research on attention networks as a model for the integration of medication as a result of the psychological sciences. Annual Review improved working memory of Psychology 58, 1-23. and executive function that is achieved11,12. While not all families agree to utilise medications, the choice is theirs and we still need to offer support to assist families to work towards improved function.
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Source: http://www.cmdfa.org.au/lukesjournal-archives/Lukes%20Vol%2013/2011-13(2)16-19_ADHD.pdf