Family & Parenting

Bouncing Off the Walls

Though ADHD is incurable, effective treatments include a combination of medicine and behavioral therapy

By Dwain Hebda

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Two bright, happy third-graders sit across the classroom aisle from one another. It’s early in the school year and hard for the youngsters to downshift from summertime freedom to the confining space of the classroom. Noon recess doesn’t seem to burn much energy, either, merely reinvigorating their desire to roam the playground and ride the swing set. 

Within the hour, both kids will be shushed more than once by their teacher, who reminds them to pay attention and stop disturbing others. The two try, but eventually their minds wander in search of more interesting subject matter.

Watching them through a two-way mirror, you probably couldn’t tell which child had Attention Deficit/Hyperactivity Disorder (ADHD) and which one didn’t. All children, at one time or another, have difficulty sitting still. But if you stretch that afternoon’s viewing across years, the picture would come into sharper focus. Left unchecked, ADHD affects a person’s behavior, learning, relationships and even puts them at higher risk for injury, depression and anxiety. 

As in a lot of medical fields, diagnosis protocol and treatment strategies for ADHD have evolved considerably from the days when a child was simply labeled “hyper” and told to settle down and try harder. Still, dealing with ADHD is an ongoing battle for many families.

“We would say to parents, there’s no cure for ADHD, there’s just management of it,” said Dr. Mark Edwards, UAMS professor of pediatrics and a clinical psychologist specializing in ADHD. “When we talk about effective treatments, we’re talking about those treatments that are showing some positive response. That would include medicines. That would include behavioral interventions that are put in place in the setting that it’s needed.”

“If we’re talking about a school-aged kid, generally 5 and older, probably the most common treatment that’s used is medication, just because that’s the most available treatment and it’s the most effective treatment as well.” 

Edwards noted the medicinal options themselves haven’t altered that much, particularly for mild or routine cases.

“Not very much has changed and a lot has changed,” he said. “What I mean by that is, the first foray in medicines for ADHD remain what we would classify the stimulant medications. Those are the category of medicines we’ve been using for 50-plus years for this condition. There have been some nonstimulant medicines that have come out, but they haven’t been as effective, so stimulants still remain the first line of medicines.

“What’s changed is, there’s lots of different preparations of the two stimulants that are used, and the preparations are different in meaningful ways. Some of it has to do with short-acting versus long-acting. You also have different ways of getting it ingested; we have skin patches versus a capsule, for instance. We have some things you can break open and sprinkle on applesauce or pudding or something for kids that don’t swallow pills.”

About 6.1 million U.S. children between the ages of 2 and 17 have ADHD, according to the American Psychiatric Association’s 2016 estimates. That’s just a hair under 10 percent of all the kids in the country, and some studies place the statistics even higher than that. 

In 2014, the New York-based ADD Resource Center ranked Arkansas second in the nation for number of children with ADHD at 14.6 percent, just behind Kentucky at 14.8 percent. While this statistic is sobering, other data shows a decent percentage of these kids are getting access to treatment. Rates of children receiving ADHD medicinal treatment, behavioral treatment or a combination of the two place Arkansas at roughly the midpoint among all states.

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“Deciding to use medicines with children, especially the younger they are, is a difficult decision for parents,” Edwards said. “Whenever I’m presenting treatments to families, I talk them through it to give them information that will allow them to assess the risks of medicines. The other way of looking at it is, there’s risks to not treating as well.

“Most of the kids with ADHD are going to be dealt with at the primary care physician level and the ‘easy cases,’ or the ones that are less severe, most of the time can be handled through their primary care doctor. They would get them started on medicine and that seems to resolve the issue.”

Edwards said he almost always recommends behavioral treatment in tandem with a medicine regimen, modified according to the severity of each individual case. 

“That’s just structuring the environment in ways that helps them be successful,” he said. “That’s always a good practice, whether in the school or at home. It’s a little bit more intensive to do behavioral interventions; there’s more commitment, especially if multiple sessions are involved. 

“We look at what we would term functional impairment, which is, how is the condition interfering with the child’s life. The more that it’s interfering, the more aggressive we might want to be with treatment. A kid who’s very severely affected, having lots of school problems, lots of social problems, lots of behavioral problems, lots of emotional problems, it’s highly likely we would recommend several things.”

Another reason for a multipronged approach is because in an overwhelming majority of cases — 67 percent, to be precise, per the APA — ADHD presents itself in conjunction with other conditions. 

“A straight-forward case of ADHD, that’s the minority of kids, a small subset of the kids that would have just ADHD,” Edwards said. “Most of them have what we would call either associated problems or they could be termed comorbid diagnoses, which is just another diagnosis that comes alongside of ADHD. A kid could have an anxiety disorder and ADHD, or they could have a learning disability and ADHD, or they could have a behavioral disorder and ADHD.

“In the research that we’ve done, the majority of kids have comorbid associated problems that may need some treatment in and of themselves. Oftentimes, what we’re talking about is a treatment plan, not so much one specific treatment.”