The Public Health Community, Parents, and ADHD

The title of a recent article from BBC News clearly sums it up: Parents ‘need lessons’ about ADHD.[1] The National Institute for Health and Clinical Excellence (NICE) is proscribing new guidelines that would offer parent training and education programs as a first-line treatment for children with ADHD. These guidelines would cover England, Wales and Northern Ireland. NICE’s stance on the treatment of ADHD with children is that drugs such as Ritalin should be avoided. Instead, NICE is implementing programs that teach parents how to create a structured home environment, encourage attentiveness and concentration, and manage misbehavior better.

America’s stance seems to be quite the opposite. In the United States, prescription for ADHD medications increased dramatically over the past decade, with consumption in many states more than quadrupling.[2] As such, the treatment of ADHD using pharmacotherapy is also a serious public health concern. The Centers for Disease Control and Prevention (CDC) points out that pharmaceutical treatment is extremely prevalent in the United States for treating ADHD, and that the health risks and benefits of this treatment to young children are still largely unknown. In fact, there may be unknown risks for young children. What’s more, pharmacologic interventions often do not normalize behavior. Research, albeit limited, suggests that even with long-term treatment, children with ADHD experience substantial problems in the school, home, workplace, and community settings. This raises questions about the effectiveness of pharmacologic interventions as a long-term approach.[3] Succinctly stated, Dr. Tim Kendall, joint director of the National Collaborating Center for Mental Health and consultant psychiatrist said “There is an over-reliance on medicines”. This over reliance is understandable, given the increasing social and cultural climate of using medication as opposed to behavioral treatment or modification to treat medical conditions. "Its easier to prescribe a drug when other options like parent training programs are not available” says Dr. Kendall.

Quite understandably, a parent may feel overwhelmed by a diagnosis of ADHD for their child, and unarmed with knowledge and resources regarding treatment options, jump at the first suggestion of treatment from their doctor which, if in the United States, will most likely be through a prescription bottle.

However, using medication to treat ADHD may be a very valid treatment option, and NICE acknowledges that it should be a first-line of treatment for children with severe ADHD (as long as they are over 5 years of age). However, CDC points out that information on the long-term effects of ADHD medications in children and calls for a national need explore different interventions and services to help individuals and children with ADHD. However, “it is clear that behavior modification therapies, for youth in particular, have been tested and shown beneficial for the treatment of behavioral disorders including ADHD” (CDC, 2005). This makes behavioral interventions to treat ADHD of critical importance.

But where are these behavioral interventions? Most people would able to name at least one of the medications often used to treat ADHD (Ritalin, Adderall, etc.). Can you name a behavioral treatment for the condition? Such treatment options severely lacking and are not communicated to parents nearly as much as pharmaceutical treatments are. “Access to [behavioral ADHD] interventions is a critical public health concern” (CDC, 2005). This leaves parents and the public at large with little options for treating ADHD.

So what is a parent to do? I think the title of BBC’s article “Parents ‘need lessons’ about ADHD” would better serve the issue of ADHD with a few additions: Public Health professionals need to do more research to understand ADHD and its treatments. Medical providers need lessons in communicating treatment options. The public needs to be better informed. Society needs a broader conception of ‘treating’ disorders, beyond the well-accepted practice of relying on medication. And yes, parents need lessons, but it is us as public health professionals to provide them.

Below are useful links and a brief description of each to information and resources for parents with kids who have been diagnosed with ADHD. Ralph Waldo Emmerson said “the first wealth is health”, and I say the first step to this first wealth- is information.

*The information and resources presented within this blog are intended to provide a general overview of perspectives and approaches to treating ADHD. Consultation with an experienced child mental health professional is recommended.*

Understanding Treatment for ADHD:

http://www.chadd.org/Content/CHADD/Understanding/Treatment/default.htm

Overview of Behavioral Treatment for ADHD

By a clinical child psychologist who specializes in the evaluation and treatment of children with ADHD. He teaches and conducts research at Duke University. Provides easy to read strategies for parents, such as using positive reinforcement, negative reinforcement, and setting schedules. Provides great Q&A’s to common questions parents may have.

http://www.athealth.com/Consumer/farticles/Rabiner.html

Section from the above article:

What can I do at home to help my child?

Children who have ADHD may be difficult to parent. They may have trouble understanding directions. Children who are in a constant state of activity can be challenging for adults. You may need to change your home life a bit to help your child. Here are some things you can do to help:
Make a schedule. Set specific times for waking up, eating, playing, doing homework, doing chores, watching TV or playing video games, and going to bed. Post the schedule where your child will always see it. Explain any changes to the routine in advance.
Make simple house rules. It's important to explain what will happen when the rules are obeyed and when they are broken. Write down the rules and the results of not following them.
Make sure your directions are understood. Get your child's attention and look directly into his or her eyes. Then tell your child in a clear, calm voice specifically what you want. Keep directions simple and short. Ask your child to repeat the directions back to you.
Reward good behavior. Congratulate your child when he or she completes each step of a task.
Make sure your child is supervised all the time. Because they are impulsive, children who have ADHD may need more adult supervision than other children their age.
Watch your child around his or her friends. It's sometimes hard for children who have ADHD to learn social skills. Reward good play behaviors.
Set a homework routine. Pick a regular place for doing homework, away from distractions such as other people, TV and video games. Break homework time into small parts and have breaks.
Focus on effort, not grades. Reward your child when he or she tries to finish school work, not just for good grades. You can give extra rewards for earning better grades.
Talk with your child's teachers. Find out how your child is doing at school--in class, at playtime, at lunchtime. Ask for daily or weekly progress notes from the teacher.

Public Health Concerns in the Treatment of ADHD-CDC

Brief summary from the CDC of why treating ADHD is a public health concern, as well as a controversial topic.

http://www.cdc.gov/ncbddd/adhd/adtreat.htm

Public Health Issues in the Treatment of ADHD Workshop- CDC

In an effort to delineate the issues in the treatment of ADHD individuals as well as gaps in treatment research, the Division of Birth Defects, Child Development, and Disability and Health (proposed)/NCEH hosted a one-day meeting with two researchers experienced in the study of ADHD treatments. This link provides an outline of the specific issues and questions related to the pharmacological and psychological treatment of ADHD.

http://www.cdc.gov/ncbddd/adhd/dadtreat.htm

FDA: Medications Used to Treat ADHD Need Better Warnings About Cardiovascular and Psychiatric Risks

The US Food and Drug Admiistration (FDA) is requiring new labels for ADHD medications due to serious health complications and averse events (including heart attack and sudden death) from taking them.

http://www.associatedcontent.com/article/157741/fda_medications_used_to_treat_adhd.html?cat=5

CDC’s ADHD Research Agenda:

http://www.cdc.gov/ncbddd/adhd/dadagenda.htm#intervention

Help and Resources for Parents with ADHD Kids:

Healthy Place ADD/ADHD Community:

Offers chat forums, info on community support groups, and tips from parents who have experience raising children with ADHD. Provides stories from parents who have been there and are ready to help.

http://www.healthyplace.com/Communities/add/Site/story_parent_help.htm

ADHD: What Parents Should Know:

Information on ADHD from American Academy of Family Physicians. Provides basic info, including how to behaviorally manage children with ADHD, as well as links to helpful resources for parents.

http://familydoctor.org/online/famdocen/home/children/parents/behavior/118.html

What Parents Can Do to Change their Child’s Behavior:

When do I use timeout? How can I use timeout so that it is effective? When should I reward my child? When should I punish them? Am I being a good parent? Why do I feel frustrated or guilty when dealing with my child sometimes? These are questions all parents ask from time to time, especially those who have children with ADHD, as a hallmark symptom of the condition is difficulty managing behavior. These two site provides answers for parents who basic parenting skills for parenting. Provided by American Academy of Family Physicians.

http://familydoctor.org/online/famdocen/home/children/parents/behavior/201.html

http://familydoctor.org/online/famdocen/home/children/parents/behavior/368.html

Positive aspects of ADHD

Does ADHD have to be considered a disorder? What if ADHD and other neurological conditions were viewed as an advantage? The concept of ‘neurodiversity’ is a fascinating new approach to understanding the many variations of mental and neurological functioning with increasing prevalence in our society.

http://www.conductdisorders.com/ourarticles/adhd.shtml

ADHD Chat/Forums:

http://chat.healthyplace.com/

http://www.babycrowd.com/forums/ADHD/

http://www.cafemom.com/

[1] http://news.bbc.co.uk/1/hi/health/7630926.stm
[2] CDC. “ADHD- A Public Health Perspective”. September 20, 2005.
[3] Lesesne, C., Abramowitz, A., Perou, R., & Brann, E. Attention deficit/hyperactivity disorder: A public health research agenda. [2000, March 15]).