The assertion that psychotropic medications, particularly the stimulants, are used indiscriminately or inappropriately by some doctors for too many children is not new. The argument usually runs something like this: symptomatic drug treatment for complex problems is superficial and poor-quality medical practice. It is ultimately doomed to failure as it does nothing to address to the causes at the root of the child’s problems. It diverts energy and attention away from the real issues, and unfairly locates the family’s complex psychosocial problems within the presented child ‘patient’, who becomes a victim of the collusion with the doctor successfully achieved by his carers.1,2 In this response I will argue that medication use is not the central issue with our current approach to attention-deficit/hyperactivity disorder (ADHD) in children from disadvantaged families; rather it is the fragmented nature of the service delivery system that often is not able to meet the needs of this vulnerable group of children.
Abstract: The functional impairments seen in attention deficit hyperactivity disorder (ADHD) are the result of a complex interplay between biological vulnerability and environmental influences. In children with ADHD from social disadvantaged families the latter often appear to predominate. Stimulant medication is the intervention with the largest demonstrable effect size in decreasing the core symptoms of ADHD, irrespective of social context. However, medication alone will not effectively treat common comorbidities, such as oppositional behaviour, anxiety, or learning disabilities. Nor can medication be expected to diminish major family discord or psychosocial adversity. Stimulant medication is one key therapy modality in children with ADHD. Data on prescribing rates do not support the assertion that there is systematic overprescribing of stimulants in Australia. There is, however, a serious problem with access to family support and appropriate services in schools for children with ADHD. Paediatricians have a responsibility to provide evidence-based medical treatment for children with ADHD (i.e. stimulant medication), while advocating across sectors for services to enhance family resilience and function.
- 1The symptoms of ADHD result from an interaction between biological and environmental factors.
- 2Stimulant medication is the single most effective therapy modality for children with ADHD.
- 3The biggest unmet needs in the care of children with ADHD are family support and school-based services.
Why Are We Seeing So Many Children with Behaviour Problems?
Children with behavioural problems are presenting increasingly to paediatricians, and now constitute one of the largest elements of outpatient paediatric practice in Australia.3 The reasons for this are undoubtedly complex, and presumably relate to both a real increase in the number of troubled children/young people, as well as a progressive expansion of the perceived utility of the paediatrician beyond assessing and managing children with traditional medical problems. There may also be greater awareness in the community that children with developmental and behavioural problems are at risk of not meeting their potential, and that addressing remediable factors as early as possible might increase the individual’s life chances.
Why should there be more troubled children now than in the past? Social trends have resulted in many modern families living in complex circumstances. Factors such as relationship breakdown, social isolation and income insecurity are common contributors to family stress. Parenting confidence and skills often erode under such pressures. Some parents face an almost overwhelming range of difficulties, including domestic violence, housing insecurity, parental mental health problems and substance abuse. These issues fundamentally and powerfully influence the nature and severity of the presentations seen by paediatricians, and to some extent the interventions realistically available to modify the child’s level of adaptive functioning.
Reduced fertility rates have resulted in smaller families. Many parents have had little experience with children until they have their own, and so have limited understanding of normal child development and lack basic parenting skills. Sole parents are a substantial group, either through relationship breakdown or the increasingly common situation of children being born to single mothers. Almost 10% of Australian families are blended or step families. This can create difficulties in terms of new attachments and shared responsibilities. Shared residency arrangements are now common, and same sex couple families are occurring more frequently. There are more families in which both parents are working, and the casualisation of the workforce has resulted in many parents working shifts at family unfriendly hours. On the other hand, more children are growing up in homes in which neither parent is working – this is sometimes seen across generations, as lack of educational opportunities restricts employment opportunities. In contrast to prior generations, many modern Australian families lack supportive informal support networks.4,5 These rapidly changing demographics have made parenting more difficult, and children’s behaviour more challenging to manage.
What Causes ADHD?
Attention-deficit/hyperactivity disorder is the term currently used to describe children with a relatively stable behavioural profile characterised by developmental inappropriate difficulties regulating impulse control and attention, causing impaired functioning at both home and school.6 It is strongly genetically determined,7 but like all developmental and health problems, the symptoms are modified by environmental influences. The relative contribution of environmental risk factors to the phenotype is the subject of a significant body of research.8 These include prenatal and perinatal insults, parenting style and other family factors, head trauma, lead exposure and electronic media. The most interesting line of research inquiry into the aetiology of ADHD is where molecular genetics studies incorporate environmental variables to investigate interactional effects.9
The alarmists sometimes confuse community prevalence estimates with the population prevalence seen in clinical samples. The former are always overestimates, often related to methodological problems in the definition of caseness. The satisfaction of diagnostic criteria is necessary but not sufficient to make a diagnosis of ADHD or recommend treatment. The diagnostic evaluation requires a detailed developmental history, information from multiple informants (i.e. parents/carers and teachers, ideally in a structured rating scale format) and evidence of significant impairment. Nobody is suggesting that 15% of schoolchildren should be on stimulant medication!
Why Prescribe Stimulants?
Stimulants are the most effective single intervention for the core symptoms of ADHD,10 although clinical practice guidelines uniformly recommend including behavioural and educational strategies in the management plan.11,12 Medications have the ability to significantly reduce symptoms, at least in the short-to-medium term. In most cases parents and paediatricians work through the assessment process together, discuss management options, and agree that a trial of stimulant medication is in the child’s best interest as it will probably reduce current symptoms, and may over time contribute to improved academic and social learning.
At times paediatricians are put under pressure from parents or teachers to ‘do something’ about a child whose behaviour is challenging. Unless something is done he will not be able to be contained in the current family/classroom environment. Somebody in the child’s world is hoping that the paediatrician will prescribe a stimulant medication to help reduce the child’s disruptive behaviour. Writing a prescription is relatively quick and easy, although best practice would involve a detailed discussion of the potential benefits and potential harms to the parents/carers as well as a developmentally appropriate explanation for the patient.
Any clinician who has some experience working in this field (i.e. any general paediatrician) knows well that stimulant medications are not a panacea. They are usually extremely effective in reducing some troubling symptoms, particularly impulsiveness and inattention. They are essentially dopaminergic/noradrenergic agents, and so can reduce the symptoms related to deficits in these amines. They cannot be expected to have any more effect than placebo on the common comorbid features of children with ADHD, such as antisocial behaviour, anxiety, language disorders and specific learning disabilities. However, at least some of these problems often improve once the ADHD symptoms are controlled.
Are We Medicating for Social Disadvantage?
So are we medicating for social disadvantage? Do paediatricians have a lower threshold for prescribing for children from adverse social backgrounds than for children with similar symptoms but whose families are relatively stable. And if so, is this bad practice?
In order to put this argument in perspective, the first question to be answered is: Is there systematic overprescribing? The best Australian data indicate that between 1% and 2% of Australian school-aged children are prescribed stimulant medication. There was a marked increase in prescribing in the first half of the 1990s, but only a slow increase in the late 1990s.13 It is known that the distribution of stimulant prescribing across geographical regions is quite uneven.13–15 It is likely that this regional variation relates to a combination of access to treating paediatricians and child psychiatrists, as well as the prescribing practices of these clinicians. Thus, there is no cause for alarm regarding escalating prescribing. Indeed some argue that, given community prevalence estimates and the well-documented adverse outcomes of untreated ADHD,16 not enough children and adolescents with ADHD are being diagnosed and treated.
Professor Isaacs highlights the particular problem of treating Aboriginal children with stimulants. There is no doubt that the removal from their own parents and communities has affected the capacity of the Stolen Generation of Aboriginal children to act as effective parents for their own children.17 Along with incarceration, poor health and early death of adults, this has resulted in fragmentation of families and the intergenerational loss of extended family networks. Support systems are weakened and there is little modelling of positive parenting. It is not surprising that children raised in these circumstances are often presented as difficult, with learning and behaviour problems, including all the DSM-IV symptoms of ADHD.
Paediatrics is often about families on the fringes. Is it not the legitimate role of the paediatrician, with an eye on the child’s life chances, to identify and reduce remedial negative influences on his developmental trajectory, while doing everything possible to enhance the family’s resilience?
Apart from proven marked reduction in core symptoms of ADHD, further arguments in favour of treating children with ADHD with stimulants include poor quality of life18 and negative outcomes of children with untreated ADHD, as well as the cost-effectiveness of treatment.19 The risk of treatment with stimulants increasing the likelihood of substance abuse is sometimes raised by parents. Fortunately there is growing evidence to the contrary.20,21 This protection presumably relates to improved impulse control resulting in less risk-taking behaviours. The possibility of long-term use of stimulants being associated with some as-yet unknown negative outcome is unlikely. The stimulants have been in widespread use since the 1970s, and no such effects have been demonstrated. It is true that no long-term benefits have been conclusively shown either. Both will be impossible to prove with certainty, as you would need a control group of subjects with ADHD who were not given treatment for a period of years. This would be unethical.
What Is the Role of the Paediatrician in ADHD?
The paediatrician is one important player in the professional support system for children with ADHD. However, at the complex end of the spectrum, doctors have a relatively limited reach and skill set with which to help children with ADHD and their families (regardless of the relative contributions of neurobiology and psychosocial adversity). Paediatricians play a key role in assessment, ideally as part of a multidisciplinary team (although in reality this is a luxury afforded to very few paediatricians or families). We are knowledgeable and skilled in prescribing and monitoring stimulant medications (the best treatment for core ADHD symptoms), and advising families in managing challenging behaviours. And we can be effective advocates, both for the individual child/family and for populations of children. For many patients with ADHD this is sufficient. For others however, the range of needs is more complex, and we need to work alongside allied health and educational professionals, and family support services, to best assist families. The biggest challenges are how to best manage comorbid problems, and how to support families in difficulty to build resilience and gain control over the lives so that they can parent more effectively. Common comorbid problems such as conduct disorder, severe anxiety and depression are best managed in partnership with mental health services. Learning difficulties, once properly assessed and described, are managed in schools with individualised educational programmes. For the socially disadvantaged, home-delivered supports may be more effective than services run out of hospitals or even community health centres. Consumer groups are leading the way in helping us to understand the challenges faced in caring for a child with behaviour problems from the family’s perspective.22 Invariably families report that lack of integration and communication between health, education, social service and juvenile justice sectors compromises their efforts to support their children. Families have enormous difficulties accessing supports at home and in schools. Mental health services continue to be difficult to access, and families commonly find their approach unsatisfactory. Efficient case management can be vitally important in achieving good outcomes, but is too often neglected.
Workforce and Training Issues
Professor Isaacs suggests we need improved access to child psychiatry services. Some child and adolescent mental health services in Australia will not see children with ADHD, unless they have seen a paediatrician first or have another mental health problem. This may actually be a rational use of resources and expertise. Paediatrics is grounded in the principles of child development, and the modern paediatrician has solid skills in the assessment and treatment of ADHD and its common comorbiities. Although I agree there is an important workforce problem in public child psychiatry in Australia, I would argue that the biggest service gaps in ADHD are educational supports and social services. The latter is particularly important for the socially disadvantaged group whose plight Professor Isaacs highlights.
Professor Isaacs refers repeatedly to ‘young paediatricians’ struggling with this sort of work. This work is difficult, for the young and the less young, whoever takes it on. Peer support and supervision is important to maintain skills and enthusiasm. We need to substantially revamp our training programmes. Paediatric trainees should be systematically exposed to developmental-behavioural work from basic training, rather than having to scramble frantically towards the end of their advanced training for appropriate training positions to equip them for consultant ambulatory care.
In summary, I agree with many of the points Professor Isaacs makes – especially his central tenet that medication alone will not solve the problems of children from severely disadvantaged backgrounds. However, I do not think that a focus on medication is the most fruitful way to move this field forward. Rather we need to do our bit as well as we can (assessment, treatment of core ADHD symptoms), while forging genuine working collaborations with colleagues in allied health, education, social welfare and juvenile justice if we are to serve this population well.
Dr Efron has been a member of advisory boards for Eli-Lilly and Novartis. These companies, as well as Janssen-Cilag, have provided educational grants to the Centre for Community Child Health.