ADHD often persists through adulthood
Dr. Hazell discusses treatment options with nonstimulant atomoxetine
Attention-deficit hyperactivity disorder (ADHD) is not a recent discovery, and neither is it a "fashion" that children can simply outgrow.
Prof. Philip Hazell of the child psychiatry research unit of the University of Newcastle, Australia, lamented that "people sometimes behave as if ADHD is a recent phenomenon," and trivialize it. "People talk about it as a fashion or a fad," he said, but recalled that as early as 1902, Dr. George Still had described some abnormal psychical conditions in children that fit the bill of ADHD.
Speaking in a symposium on recent ADHD research findings and treatment options using atomoxetine (Strattera) organized by Eli Lilly Philippines in January, Hazell also noted that ADHD may persist through adulthood. Few patients achieve remission before high school, he said, citing studies that placed the rate of persistence at between four percent and 80 percent of cases. Some also argue that up to 90 percent of children with ADHD experience residual symptoms in adulthood although they may no longer present major impairments in their lives.
Good days, bad days
The core symptoms of ADHD involve inattention, problems with regulating activity, and impulsive behavior. However, Hazell said that these are typically inconsistent as patients may have good days and bad days. Some have good weeks then bad weeks. "I have an exceptional patient with good months and bad months," he said.
And then there are comorbid conditions--conduct disorder, anxiety disorder, and depression. Poor concentration leads many ADHD patients to struggle with school, and many would be aggressive and prove difficult, with attendant motor discoordination.
For adults with ADHD, lower educational attainment with poorer occupational functions and driving problems are common. Relationship problems lead to a high rate of separation and divorce. Anxiety, depression, substance abuse, and bipolar disorder are also prevalent. But Hazell stressed that the overlap between ADHD and bipolar disorder is somewhat controversial.
Although the exact causes of ADHD are unknown, mounting evidence supports the genetic theories on the presence of an apparent abnormality in the dopamine-transporter gene. Other theories involve neurotransmitter dysfunction possibly with noradrenaline, perinatal hazards, environmental toxins, and the psychosocial theory on parenting problems.
Mania versus ADHD
It's hard to find a bipolar child who doesn't have syndromal ADHD, said Hazell. "It seems all children and adolescents with mania meet the criteria for ADHD…but critics point out the absence of the biphasic bipolar pattern in those children with ADHD. Both will be moody, but in ADHD [it] tends to be quite transient, over in a couple of minutes. [On the other hand], the rage attacks of bipolar disorder can go on for hours and hours."
In addition, patients with bipolar disorder are less likely to have neuropsychiatric correlates, clumsiness, discoordination, and soft neurological signs. One would also find a family history of ADHD, not bipolar disorder, in a child with ADHD.
Treatment strategies
Educating parents and teachers about the condition is vital in ADHD management, said Hazell. Parents and teachers must be informed about the condition, what to expect from it, and what the course of the condition is likely to be. Behavior management strategies are also important. Cognitive therapies are applicable but limited to specific settings. Pharmacotherapy is a viable option for children with a high degree of social or academic impairment, whose symptoms may be static or worsening, and who meet diagnostic criteria, with no contraindications.
Apart from psychostimulants, the only other agent approved for use in ADHD is Strattera. Hazell said using Strattera requires patience because unlike psychostimulant drugs that generate treatment response within one to three days, Strattera takes six to eight weeks to have true effects. "With atomoxetine, patience is rewarded because the true clinical effect takes a while to settle in," noted Hazell.
Hazell said that one advantage Strattera has is that it may be given once daily with the same efficacy in reducing symptoms of hyperactivity, impulsiveness, and inattention as twice daily as shown in a study. The effects also last through the day until evening, helping patients cope with the difficulties of doing homework, sitting through dinner, and settling down and getting ready for bed.
As for maintenance, Hazell left this bit of advice: "While the individual is still impaired by ADHD or where a relapse in ADHD symptoms would cause significant impairment, it is not worth the risk of stopping….It is better to continue with the treatment, typically until mid-high school, often beyond." He stressed it is best to involve young people with ADHD in deciding whether or not to continue with treatment.
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