Drugs for ADHD 'not the answer'

[Keevan_Colton]

Treating children who have Attention Deficit Hyperactivity Disorder (ADHD) with drugs is not effective in the long-term, research has shown.

A study obtained by the BBC's Panorama programme says drugs such as Ritalin and Concerta work no better than therapy after three years of treatment.

The findings by an influential US study also suggested long-term use of the drugs could stunt children's growth.

It said that the benefits of drugs had previously been exaggerated.

The Multimodal Treatment Study of Children with ADHD has been monitoring the treatment of 600 children across the US since the 1990s.

'Exaggerated impact'

Most of the estimated 500,000 children in Britain with ADHD receive no treatment at all.


DH STATEMENT

The Department of Health has issued a statement on the treatment of ADHD

But of those that do, most - about 55,000 last year - are prescribed stimulants like Ritalin and Concerta.

The cost of these drugs to the NHS is about £28m.

In 1999, the American study concluded that after one year medication worked better than behavioural therapy for ADHD.

This finding influenced medical practice on both sides of the Atlantic, and prescription rates in the UK have since tripled.

But now after longer-term analysis, the report's co-author, Professor William Pelham of the University of Buffalo, said: "I think that we exaggerated the beneficial impact of medication in the first study.

"We had thought that children medicated longer would have better outcomes. That didn't happen to be the case.

"There's no indication that medication's better than nothing in the long run."

Prof Pelham said there were "no beneficial effects" of medication and the impact was seemingly negative instead.

"The children had a substantial decrease in their rate of growth so they weren't growing as much as other kids both in terms of their height and in terms of their weight," he said.

Aggressive behaviour

The Panorama programme features disturbing footage of a 14-year-old from Stoke-on-Trent, who has been on ADHD medication for a decade.

Craig Buxton's family kept a video diary of his behaviour and captured on camera examples of just how explosive his behaviour can be.

He has self-harmed, suffers night terrors and is aggressive - he recently assaulted three school teachers.


And all I can do is go back to the doctors and say: 'Is there anything more you can do?'
Sharon Buxton
Mother of child with ADHD

Your comments and views

His mother Sharon said things had gone from bad to worse.

"He has broke down and cried when he gets into situations," she said.

"He says: 'Why am I like this mum, I don't want to feel like this, I don't want to be like this, you know, help me'.

"And all I can do is go back to the doctors and say: 'Is there anything more you can do?'

"All they say is, well, we are doing what we can."

The National Institute for Clinical Excellence is currently revising the treatment guidelines for ADHD.

Chair of the working group Dr Tim Kendall said they were devising a strategy which was likely to involve training for parents as well as "behavioural interventions".

"The important thing is that we have an approach which doesn't focus just on one type of treatment," Dr Kendall said.

Panorama: What Next for Craig? BBC One 8.30pm, Monday 12 November 2007

[Isolder74]

I could have told you that.

I am ADHD. I had to deal with being drugged up when I was kid but I had a major reaction to the drug so I had to use other meathods to deal with the problem. they worked much better I think.

[Superman]

Do you have a link for the article?

My experience with Dexedrine, a stimulant medication in the same class of drugs the article is referring to, has been tremendously positive. It has improved my life tremendously; even my wife and family were shocked at the improvements. Of course, this is my experience, but it would seem to concur with the majority of people diagnosed with ADHD and treated with medication. I am also receiving treatment from a psychiatrist once per week via psychotherapy.

This article is from Medscape.com. It requires an account, so I'm not sure you can log on, but I'll link you if you want. It's a bit lengthy, so I'll post the results.

Comparing the Efficacy of Medications for ADHD Using Meta-analysis

Discussion

Our meta-analysis of ADHD efficacy outcomes found significant differences between stimulant and nonstimulant medications, even after correcting for study design features that might have confounded the results. We found no evidence of publication bias for any of the 3 classes of medication. Our analyses indicate that effect sizes for stimulants are significantly greater than those for other medications, but the presence of confounds and their interaction with medication class suggests that, in the absence of confirmatory head-to-head studies, caution is warranted when comparing the effects of different medications across studies. Although head-to-head trials are needed to make definitive statements about efficacy differences, our results comparing stimulants and nonstimulants are compatible with the efficacy differences between atomoxetine and mixed amphetamine salts reported by Wigal and coworkers[31,32] and the conclusions of a prior review limited to a smaller subset of studies that excluded short-acting stimulants.[26]

Table 1 shows little uniformity in the study design parameters used to assess medication efficacy. Although this does not affect the interpretation of individual studies, it makes difficult the comparison of the efficacy of different medications in the absence of direct comparisons within the same study. This problem is further compounded by the fact that effect sizes, which compare treatment efficacy, differ according to study design variables. Comparing medication effect sizes in different studies will lead to spurious conclusions without accounting for these influences. We found that 2 key design variables -- type of score (change score or outcome score) and study design (crossover vs parallel) -- differed significantly among the medication groups. When we adjusted for these differences using meta-analysis regression, however, we continued to find significant differences among classes of medications, although these differences could not be established for the 3 different methodologic strata that potentially confounded results.

The robust effects of all ADHD medications can be seen in Figures 1 through 3, which show that most measures of effect from all studies were statistically significant. Also notable is that, for nonstimulants and short-acting stimulants, variability within each medication class was not statistically significant. This suggests that, within each medication class, studies measure a common effect size. For long-acting stimulants, there was modest evidence of significant interstudy variability. Inspection of Figure 3 suggests that this is due to the very high effect sizes reported by James and colleagues[33] and the low effect size reported by Wilens and associates.[34]

The interpretive difficulties created by confounding design variables are clearly seen in Figures 1 through 3. Notably, studies using outcome scores from crossover designs were only used for stimulant medications, which is sensible given that the crossover is not suitable for drugs having longer half-lives. The 95% confidence intervals from Figures 1 through 3 show that, although there are systematic differences among classes of medication, the variability within each study is high, which makes it difficult to compare individual pairs of studies or pairs of drugs. The Figures also show that within the strata defined by confounding variables, there are no apparent differences among the stimulants or among the nonstimulants.

This work must be interpreted in the context of several limitations. Because we relied on data presented by authors, we could not assess the effects of all potential confounds. We were limited by what other investigators chose to present. For example, we could not compute the effect sizes at specific time points, because such data were rarely provided. Future work should review studies of time course such as the analog school laboratory paradigm. Although that work does not assess outcome in the patient's environment, it would provide useful data about efficacy peak or trough effect. Similarly, we did not assess differential duration of action between medication classes, but this effect is rarely presented. All meta-analyses are limited by the quality of the studies analyzed. For that reason, we limited our review to double-blind, placebo-controlled studies that diagnosed ADHD using DSM-IV criteria. Nevertheless, although our analyses controlled for several study design features, it is possible that systematic methodologic differences between drugs or classes of drugs might have led to spurious results. For example, in Figure 1, we see that the effect size reported from Wilens and colleagues'[34] study of MPH OROS was much lower that that seen for other MPH OROS studies and other long-acting stimulants. Wilens and colleagues note that because patients were not dosed to optimal outcome, their results might be less that expected with optimal dosing. Similarly, Zeiner and coworkers'[35] study of methylphenidate reported a low effect size using doses of 0.5 mg/kg, which is relatively low by current standards. Effects of this sort that are idiosyncratic to one or a few studies cannot be adjusted for in a meta-analysis context.

Despite these limitations, our findings highlight the remarkable variability in methods among ADHD treatment studies. Although this does not argue against the validity of individual studies, it highlights the difficulty that one faces when interpreting differential medication efficacy when a direct comparative trial is not available. Yet, despite this variability, we found substantial and significant differences in efficacy between stimulant and nonstimulant medications. Although efficacy effect sizes should not be the sole guide for clinicians to use when choosing an ADHD medication, they do provide useful information for clinicians to consider when planning treatment regimens for patients with ADHD.

One of the highlights of this study is that, at least in the short term, stimulant medications are very effective for most people.

[Keevan_Colton]

Link

[Superman]

Thanks!

Is it just me, or is there no source given by the news agency?

[Superman]

Also, here's another I was just reading from the Medscape research journal. It seems to also conflict with this.

Stimulant Treatment Linked With Improved Long-Term School Outcomes in ADHD

Marlene Busko

Medscape Medical News 2007. © 2007 Medscape

October 8, 2007 — Two reports from a retrospective, population-based study that followed 370 children with attention-deficit/hyperactivity disorder (ADHD) from birth to age 18 years found that first, compared with control children, those with ADHD had poorer long-term school outcomes. Second, treatment of ADHD with stimulant medication was associated with improved reading achievement, decreased school absenteeism, and decreased likelihood of being held back a grade.

The 2 articles are published in the August issue of the Journal of Development & Behavioral Pediatrics.

"Previously, there was evidence that treatment with stimulant medication improved short-term academic performance, but there was no good evidence that long-term outcomes are better with stimulant treatment," said lead author William J. Barbaresi, MD, from the Mayo Clinic in Rochester, Minnesota, in a press release issued by that center. "Our data can guide clinicians in their efforts to help children with ADHD succeed in school."

The researchers looked at data from a population of all children who were born in Rochester, Minnesota from 1976 through1982 (n = 5718). A total of 370 children (277 boys and 93 girls) had research-identified ADHD. These children were matched by age and sex with 740 children in this birth cohort who did not have ADHD. The subjects were followed from birth to a median age of 18.3 to 18.4 years.

"All Children with ADHD at Risk of Academic Underachievement"

The median California Achievement Test reading score at the last assessment at an average age of 12.8 years was significantly lower for the children with ADHD than for the control children (45 vs 73, expressed as a national percentile). Children with ADHD were 2.7 times more likely than control subjects to drop out of school before high school graduation (22.9% vs 10%). They were also 3 times more likely than their peers to be held back a grade, and they were absent from school more often.

"This indicates that all children with ADHD should be considered to be at risk of academic underachievement and impaired school function," the group writes, adding that parents, clinicians, and educators should work together to ensure that children with ADHD receive appropriate long-term monitoring, support, and intervention to ensure optimal educational outcomes.

Need for Appropriate Long-Term Treatment

A total of 272 of the 370 children with ADHD obtained treatment with stimulants (methylphenidate, dextroamphetamine, levoamphetamine plus dextroamphetamine, pemoline, or methamphetamine). They received a median of 30.4 months of treatment, which was typically started during elementary school years.

There was no difference in the stimulant-treated and nontreated groups in their average reading score at the time of the last assessment or in their dropout rate (22.2% vs 25.8%). On the other hand, there was a slight positive correlation between the average daily stimulant dose and the last reading score. Also, compared with the children with ADHD who did not receive stimulants, those who did were 1.8 times less likely to be held back a grade, and they had a lower rate of absenteeism.

"This study provides support for efforts to ensure that children with ADHD receive appropriate long-term medical treatment," the group writes.

[Keevan_Colton]

The study that the Beeb is talking about highlights medical problems of decreased growth and that there is no statistical benefit to drugs over behavioural therapy which doesnt have the same risks of stunted development. Not that it isnt better than nothing at all, just that it is no better than the alternative and has serious drawbacks.

[Bob the Gunslinger]

I have also had an incredibly positive experience with dexedrine. When I was a child, I was diagnosed with ADD, but my parents did not want to medicate me. Instead, they tried all kinds of diet fads and vitamins and I was in constant ADD therapy with at least 3 different psychologists. I was still failing at school and even my own dad thought I was lazy (because he knew it wasn't that I was stupid).
Once I started the medication, my grades changed from Cs, Ds and Fs to straight As. I probably would not have made it into university if it weren't for the medication.
The medicine also affected my social life and my happiness due to the increase in concentration and confidence, especially the confidence. After more than a decade of being told there was something wrong with me or that I was stupid and lazy, I was suddenly vindicated. To put it simply, the medication allowed me to have a normal life.

[Adrian Laguna]

Drugs like these tend to work for some people, and do jack and shit for others. Any doctor worth his salt would, upon deciding to try the drug on a patient, recommend that usage be suspended if there is no marked improvement in behaviour.