A recent review conducted by U of T psychiatry professor Dr. Alice Charach suggests that for hyperactive (read: normal) children under six years old, behavioral interventions are more effective and, more importantly, much safer than pharmacological treatment.

Charach, who is the head of neuropsychiatry at Sick Kids Hospital, examined the effectiveness of various approaches to Attention Deficit Hyperactivity Disorder. The aim of the review was to provide information that will lead to improvements in approaches to treatment of the disorder in children.

Attention Deficit Hyperactivity Disorder, known on the playground as ADHD, was first identified and described as a clinical condition in the early 1900s. Since its inclusion in the second edition of Diagnostic and Statistical Manual (DSM-II) in 1968, the condition, characterized by “inattention, overactivity, and impulsivity” has been classified, re-labeled, and ultimately recognized as a treatable disorder by the medical community.

In recent decades, the disorder has become increasingly common among elementary school children. However it remains unclear whether it is the prevalence of the condition or simply the rate of diagnosis that has truly increased.

While this question invites some epidemiological truth-seeking, more immediately pertinent is the effectiveness and safety of existing treatments. Charach noted that, “the rate of prescriptions for psychotropic drugs to treat ADHD has been going up steadily since the early 1990s.” This trend has continued, despite the lack of knowledge regarding the long-term effects of medication. Although there are a number of behavioural approaches, interventions and treatment for ADHD have been overwhelmingly pharmacological.

“In children under six, diagnosis and rates of medication have increased from about one per cent to nearly three per cent in recent years,” Charach explained. This has raised concerns because the majority of medications prescribed are not yet approved for use among this age group. In general, there is a paucity of what can be considered ‘good quality’ studies examining the effectiveness and effects of commonly prescribed medication.

However limited, existing studies on pharmacological intervention for ADHD clearly show there are adverse effects in children under six. According to Charach, younger children are more susceptible to the side-effects of the medication, often becoming more irritable and ill-tempered. Of greater concern perhaps, are indications that pharmacological intervention in younger children may inhibit height and weight gain, and slow down overall growth.

“The rate of diagnosis and treatment rises dramatically after kids hit school, from about age 7 or 8 until age 12, then it drops off.” Charach noted, emphasizing that “[ADHD] is a neurobiological difficulty,” which is present in some children, relative to their same age peers. However, Charach underlined the correlation between ADHD diagnosis and age group.

“This really does mean it has something to do with when children go to school and have to sit quietly and learn,” said Charach, “The youngsters who are easily distracted and impulsive . . . have a lot of difficulty in the classroom.” These children are more likely to be diagnosed with ADHD and given medication.

In younger children, it is more challenging to recognize the distractibility, overactivity, impulsiveness and oppositional behaviour that are associated with ADHD. Thus, in children under six, it is difficult to arrive at a diagnosis. Unfortunately for some parents, handling an overactive child can prove to be its own challenge and there is an increasing tendency to pathologize and treat children’s behaviour with pharmacological interventions.

However, the most significant piece of evidence discovered through Charach’s review was that Parent Behavior Training (PBT) is the most effective method of treatment in improving a child’s behaviour. The evaluative measures looked at the levels of generalized disruptive behaviour in the children, and the effects of PBT on other ADHD symptoms.

Charach explained that PBT focuses on “explaining child development and behaviour to parents, and really helping them figure out how to be more patient and less easily frustrated by their kids.” This type of intervention not only involves parents, but invests them with primary responsibility when it comes to the treatment of ADHD for their children. “Improving the warmth and caring of the parents is an important basic,” said Charach. Her findings recommend PBT as the most effective and certainly the safest immediate and long-term treatment.

The only downside to PBT is that it is not always easy for parents to access and complete training programs. However, Charach’s findings demonstrate that even when medication appears necessary, PBT is an important complement and that improvements in ADHD are greatest when the interventions accompany one another. “I hope that our systems of care will make it much more easy for parents to access these training programs,” Charach said with regard to the future of ADHD treatment. Indeed, her review sheds light on efficacious alternatives to medication, for children of all ages.

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  • Subtitle: U of T psych prof doubts ADHD children need medication
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