ADHD: Overdiagnosed and overtreated, or misdiagnosed and mistreated?
ABSTRACT
In today’s changing medical climate, physicians need to treat attention-deficit/hyperactivity disorder (ADHD) better and more cost-effectively. The authors review recommendations supported by recent research and offer simple practices that integrate medicine and behavioral health for patients with ADHD.
KEY POINTS
- Despite concerns about overdiagnosis and overtreatment, many children and youth diagnosed with ADHD still receive no treatment or insufficient treatment.
- Today, more children are prescribed drug therapy when ADHD is diagnosed, but the initial titration of medication is often done without sufficient physician supervision.
- ADHD symptoms improve with drug therapy, but improvement is inconsistently sustained due to poor treatment adherence.
- Drug therapy and behavioral therapy work together. Outcomes can be determined by measuring both improved behaviors and reduced symptoms.
STRATEGIES FOR TITRATION
Physicians typically rely on 4 strategies to titrate stimulants,16 presented below in order of increasing complexity.
Prescribe-and-wait
Often, physicians write a prescription and direct the parent to call back or visit the office to relay the child’s response after a specified period, typically 1 week to 1 month.
This method is convenient in a busy practice and is informative to the physician in a general way. The drawback to this method is that it seldom results in optimal treatment. If the parent does not call back, the physician may assume the treatment was successful without being certain.
Dose-to-improvement
In this approach, the physician monitors titration more closely and increases the dose until a positive response is achieved, after which the dose is maintained. This method reduces symptoms but does not ensure optimal treatment, as there still may be room for improvement.
Forced-dose titration
This method is often used in clinical trials. The dose is ramped up until side effects occur and is then reduced until the side effects go away.
This method often results in optimal dosing, as a forced dose yields a greater reduction in symptoms. But it requires close monitoring by the physician, with multiple reports from parents and teachers after each dose increase to determine whether benefit at the higher dose outweighs the side effects and whether side effects can be managed.
Blinded placebo trial
Also often used in research, this method typically requires a research pharmacy to prepare capsules of stimulant medicine in low, moderate, high, and placebo doses.17 All doses are blinded and given over 4 weeks in a forced-dose titration—a placebo capsule with 3 active medication doses in escalating order, which is typical of outpatient pediatric practice. Placebo capsules are randomly assigned to 1 of the 4 weeks, and behavior is monitored over the 7 days of administration by teachers and parents.
This strategy has benefits similar to those of forced-dose titration, and it further delineates medicine response—both side effects and behavior change—by adding a no-medicine placebo condition. It is a systematic, monitored “experiment” for parents who are wary or distrustful of ADHD pharmacotherapy, and it has notable benefits.18 It is also useful for teenagers who are reluctant to use medicine to treat symptoms. It arrives at optimal treatment in a timely manner, usually about 4 to 5 weeks.
On the other hand, this approach requires diligence from families, teachers, and caregivers during the initiation phase, and it requires consistent engagement of the physician team.
Some pediatricians designate a caregiver to monitor titration with the parent; with each new weekly dose, the caregiver reports the child’s progress to the physician.
ENSURING ADHERENCE
Essential to effective stimulant treatment for ADHD is not whether the medicine works (it does),19 but whether the patient continues to use it.
In treatment studies and pharmacy database analyses, rates of inconsistent use or discontinuation of medication (both considered nonadherence) were 13.2% to 64% within the first year,20 and more than 95% of teenagers discontinue pharmacotherapy before age 21.21
Clinician engagement at the onset of stimulant titration is instrumental to treatment adherence.22,23 When pharmacotherapy is loosely monitored during initiation, adherence is highly inconsistent. Some physicians wait as long as 72 days after first prescribing a medication to contact the patient or family,7 and most children with ADHD who discontinue their medications do so within the first year.24
FACTORS THAT INHIBIT ADHERENCE
What factors inhibit adherence to successful pharmacotherapy for ADHD?
Treatment nonadherence is often associated with a parent’s perception that the medication is not working.25 Physicians can often overcome this perception by speaking with the parent, conveying that at the start of treatment titrating to the optimal dose takes time, and that it does not mean “something is wrong.” But without physician contact, parents do not have the occasion to discuss side effects and benefits and tend not to voice fears such as whether the medicine will affect the child’s physical development or result in drug abuse later in life.26
At the beginning of treatment, a child may become too focused, alarming the parent. This overfocused effect is often misunderstood and does not always persist. In addition, when a child better manages his or her own behavior, the contrast to previous behavior may look like something is wrong, when instead the child’s behavior is actually normalizing. Medicine-induced anxiety—in the child or, by association, in the parent—may be misunderstood, and subsequently the parent just stops the child’s treatment rather than seek physician guidance.
Nonadherence is also more prevalent with immediate-release than with extended-release formulations.27,28
Problems can be summarized as follows7:
- Systematic physician observation of response to stimulant titration is often missing at the onset of treatment
- “Best dose” is inconsistently achieved
- Patient adherence to treatment is inconsistently monitored.
The long-term consequences of nonadherence to therapy for ADHD have not been sufficiently examined,20 but some groups, especially adolescents, show problematic outcomes when treatment is not applied. For example, in one longitudinal study, substance use disorder was significantly higher in youths with ADHD who were never treated with medicine than in “neurotypical” youths and those with ADHD who were treated pharmacologically.29
