Thursday, 3 August 2017

The pharmacological and non-pharmacological treatment of paediatric ADHD

The findings - "systematic review with network meta-analyses" - reported by Ferrán Catalá-López and colleagues [1] (open-access available here) on the topic of treating attention-deficit hyperactivity disorder (ADHD) were expected [2].

Looking at the available peer-reviewed science comparing "the efficacy and safety of pharmacological, psychological and complementary and alternative medicine interventions for the treatment of ADHD in children and adolescents" authors identified nearly 200 randomised trials looking at various intervention options. With data from over 26,000 people diagnosed with ADHD to examine, they applied some nifty statistical analyses leading to various conclusions on the basis of their categorisations of the various interventions analysed: "pharmacological (stimulants, non-stimulants, antidepressants, antipsychotics, and other unlicensed drugs), psychological (behavioural, cognitive training and neurofeedback) and complementary and alternative medicine (dietary therapy, fatty acids, amino acids, minerals, herbal therapy, homeopathy, and physical activity)."

First: "behavioural therapy (alone or in combination with stimulants), stimulants, and non-stimulant seemed significantly more efficacious than placebo." I don't think this is a particularly novel finding given the intervention options typically indicated for ADHD (see here).

Then: "Behavioural therapy in combination with stimulants seemed superior to stimulants or non-stimulants." This is important insofar as any notion that use of pharmacotherapy alone is going to 'tackle' ADHD. It also suggests that parents, teachers and significant others have a role to play in managing the symptoms of childhood ADHD as per various examples (see here).

Also: "Most of the efficacious pharmacological treatments were associated with harms (anorexia, weight loss and insomnia), but an increased risk of serious adverse events was not observed." It should be no surprise to anyone that there is a cost-benefit balance to be struck when it comes to pharmacotherapy for ADHD or anything else. Medicines always have the potential for side-effects. The lack however, of 'serious adverse events' noted by Catalá-López et al is reassuring and adds to other reviews (see here) highlighting a role for regular monitoring and good medicines management with specific regards to medicines indicated for ADHD.

Finally: "There is lack of evidence for cognitive training, neurofeedback, antidepressants, antipsychotics, dietary therapy, fatty acids, and other complementary and alternative medicine." I don't disagree with these findings but do find it a little 'odd' that other systematic reviews/meta-analyses of something like dietary interventions and/or use of fatty acids for ADHD have come to slightly different conclusions (see here and see here respectively). I don't doubt that there are going to be some subtle differences in what studies were included for further analysis and the interpretation of findings, but 'lack of evidence' is, in my mind at least, perhaps not an entirely accurate viewpoint. Indeed, a more recent paper is a further case in point [3].

"An open and honest discussion with parents and older children about uncertainties of available treatments and the balance between benefits, costs, and potential harms should be established before starting treatment." I think a sentence like this should be added to every article trying to arrive at a coherent statement for many different behavioural and psychiatric labels. It tells us that whilst scientific progress is being made when it comes to the important management of ADHD (see here), there typically is no one-size-fits-all 'silver bullet' that will vanquish all of the challenging symptoms of ADHD and onward improve current and future quality of life. Added to the idea that a multi-pronged approach to managing ADHD is typically better than any one single intervention option, and the Catalá-López article might turn out to be something rather important for many different people with various degrees of interest in ADHD and beyond.

Music: and when Mars Attacks...

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[1] Catalá-López F. et al. The pharmacological and non-pharmacological treatment of attention deficit hyperactivity disorder in children and adolescents: A systematic review with network meta-analyses of randomised trials. PLoS One. 2017 Jul 12;12(7):e0180355.

[2] Catalá-López F. et al. The pharmacological and non-pharmacological treatment of attention deficit hyperactivity disorder in children and adolescents: protocol for a systematic review and network meta-analysis of randomized controlled trials. Systematic Reviews. 2015;4:19.

[3] Chang JC. et al. Omega-3 Polyunsaturated Fatty Acids in Youths with Attention Deficit Hyperactivity Disorder (ADHD): A Systematic Review and Meta-Analysis of Clinical Trials and Biological Studies. Neuropsychopharmacology. 2017 Jul 25.

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