How to treat ADHD
After making a diagnosis of ADHD, attention deficit hyperactivity disortder, inevitably thoughts turn to managing the condition. But what does treatment look like? Max Davie is a consultant paediatrician and works with ADHD UK, and he took Chris Smith through the treatment options...
Max - Broadly speaking, the two sorts of intervention that I think are most useful are - one, environmental modification. And then secondly, medication. In children, the first one comes first, the environmental modification. So we would look at how people understand the condition around the child, we'd look at the child's brain health - so essentially that's exercise, sleep and mood. We would support the family at home, and this could be anything from a parenting intervention, to just helping them to sort out their housing - that can be a really crucial element. We need to support them in school, and for an older person into employment or training, make sure everyone understands and that they get the reasonable adjustments that are required within schools to help them through. And then medication at the end, generally, in children, when those things have been sorted out as far as we're able. That's the kind of structure of the interventions anyway.
Chris - What sorts of things in the environment tend to be bad triggers for people that will disclose more ADHD type negative effects?
Max - Yeah. I think you've put that really well actually in that they don't cause ADHD, but they make the ADHD more troublesome. So I mean there's so many of them, but I think a harsh and negative either school or parenting environment will make things worse. Poor sleep is a really big trigger and you can get into a real vicious cycle of sleeping worse, so therefore your behaviour is worse, then your mood is worse. And therefore as any parent will know an irritable and sleep deprived child is often actually harder to get to sleep subsequently. So you can really get into a big problem there. So I think those are two really big ones for me.
Chris - I know you're a paediatrician, but presumably a lot of what you've just said also applies to adults.
Max - Yeah, a hundred percent. I think there is a distinction to an extent in that medications are offered earlier for adults, but the principles are exactly the same. I think that's really important to emphasise.
Chris - Now there's going to be something of a tension because people don't like taking medicines if they can avoid it. And we see this with a whole spectrum of different diseases, whether it's high blood pressure or say depression. People prefer not to have to take medications. But there's an additional element when it comes to children, isn't there, because people are concerned. Medicating children has a whole range of different sorts of manifestations and negative associations, but one of them is people are concerned that because the young brain is still developing, perhaps that could alter its development in unforeseen or perhaps negative ways. Is there any truth to that?
Max - I think the evidence so far is that giving medication to a child who has ADHD, and you've made a proper diagnosis, is probably a benefit to their cognitive development because it gives them more positive experiences. Everything that we do, everything that we put into our bodies or experience, changes our brains. I think that if you give the right medication at the right dose to the right child, it will actually, by giving them vastly more positive experiences going forward, will positively impact their brain development. So I'm not worried about that really.
Chris - And the medications that we use, what are they and how do they work?
Max - Basically they're stimulants, which broadly speaking will stimulate those parts of your brain which supervise the rest of the brain. And they are things like methylphenidate. They are very effective, but they do have some side effects. And then there are non-stimulants, which tend to be a little bit less likely to be effective, but they are a little bit gentler, take a bit longer to work, and they sort of alter the kind of balance of the brain. And they kind of alter the way that these supervisory elements can communicate with the rest of the brain. So two different classes of drugs that work in slightly different ways and can work together quite nicely. So we have a few kind of tricks up our sleeves, even if the first thing we try doesn't work.
Chris - And is that an indefinite thing? People then are almost, I don't want to use the word condemned, but it almost is like that, you have to continue to use these medications indefinitely in order to continue to get that effect?
Max - It's not a life sentence. I suppose my experience is mainly with children and very often what I will say to people, quite often the children are starting this at sort of age seven or eight, and the parents will rightly ask me, is this going to be forever? And I suppose my answer is if it works and they tolerate it, we're probably in for a stretch up until secondary school. And then, frankly, the young person will tell you whether or not they want to carry on with it. And you know they're very clear about that very often. And if they want to carry on with it then they can.
Chris - And do most people elect to carry on?
Max - I mean, well, it's really interesting. My experience in clinical practice is that most people do, but actually, if you look at some of the data on following people up with medication, there is really quite a high dropout rate. But it's just not something that I experienced personally, so I've never quite squared that circle if I'm completely honest.
Chris - And do we have any data on people who do go on medication versus people who don't, is there a sort of a clear direction from beneficial outcomes as to what the best choice is?
Max - So the best data comes from Scandinavian birth registries, as it often does when you're looking at chronic conditions. The comparators that are treatment versus non treatment. So it's not non-pharmacological versus pharmacological treatment. So it's not drug versus non-drug, it's treatment versus non-treatment, but the benefits of treating these conditions over not doing so are absolutely legion. The most striking, the most eye-popping, is that if you treat ADHD, your chances of getting involved in the criminal justice system are halved.
Chris - That's a staggering difference.
Max - It is really staggering. I mean, it's a fairly low number already, but it really is a big big difference. Advantages in employment, education, relationships, all the way through, treating ADHD is better than not treating it. It's not quite the same as saying "the medications do this". And there's a bit of an unanswered question about to what extent medication versus these other environmental modifications or supporting the person's mental health are the crucial elements, but certainly going to seek treatment, getting a diagnosis where it's appropriate, is unequivocally a good thing.