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This activity is not sanctioned by, nor a part of, the American Psychiatric Association. Conference news does not receive grant support and is produced independently.

This activity is not sanctioned by, nor a part of, the American Psychiatric Association. Conference news does not receive grant support and is produced independently.

New Evidence in Pediatric ADHD: An Expert Interview With Paul G. Hammerness, MD

Authors: Paul G. Hammerness, MDFaculty and Disclosures


Editor's Note: Research into effective pharmacologic treatment for attention-deficit/hyperactivity disorder (ADHD) continues to be one of the most active areas of investigation in all of child psychiatry. A number of new agents have been introduced within the past 2-3 years, with many in development. A wide range of pharmacotherapy data was presented at the 162nd Annual Meeting of the American Psychiatric Association (APA). On behalf of Medscape, Craig B. H. Surman, MD, Scientific Coordinator of Adult ADHD Research at the Massachusetts General Hospital in Boston, Massachusetts, discussed some of this research, as well as a recently published 8-year follow-up of the Multimodal Treatment Study of Children With ADHD (MTA), with his colleague, Paul G. Hammerness, MD, who is Assistant Professor of Psychiatry at Harvard Medical School and Scientific Coordinator of Pediatric ADHD Research, at the Massachusetts General Hospital.

Dr. Surman: You and a number of clinicians in the ADHD field are presenting research here on treatments for ADHD. I'd like to start by talking about one of the studies you participated in that looked at the effects of treatment on early morning, before-school functioning.

Dr. Hammerness: Our group from Massachusetts General Hospital is committed to generating clinical studies that are relevant to the real world -- studies that look at functionality and the real impairment that we see in kids. These days we are looking very broadly at how clinically significant inattention, disorganization, and impulsivity affect the lives of children and adults.

At this year's APA, we are presenting the results from a short-term study of methylphenidate transdermal system (MTS); we examined whether treatment improves a child's ability to get out the door in the morning -- that is, improves organization and behavior even before school starts.[1] This was a 4-week crossover study: participants received the MTS or a placebo patch for 2 weeks, and then crossed over to the alternate patch. Subjects met with clinicians on a weekly basis during that time, and were assessed with 3 different scales. Our primary outcome measure was the ADHD rating scale, which measured symptoms throughout the day. Secondary outcome measures included a scale that I developed with Tim Wilens, MD, the Wil-Hammer Scale, to quantify dysfunction before school. The Wil-Hammer Scale is a multi-item scale that inquires about ADHD symptoms as they relate specifically to morning, before-school functioning. For example, is the child able to follow directions, such as to get to the table to sit for breakfast; able to prepare himself or herself and collect items for school; able to make it on time for the bus? In addition, we used the standard ADHD rating scale, asking only about morning time.

The participants were a typical population of children with ADHD: about 9 years old, roughly 50% had prior medicine exposure, and typical comorbidities, namely, oppositional defiant disorder. We found that these children had a very good response to the active MTS as compared with the placebo patch, with superior improvements in ADHD rating scale score as well as the specific morning assessments -- the Wil-Hammer and the ADHD rating scales, morning rated. There were typical side effects in the study that you would see with short-term treatment with this kind of stimulant. It is an interesting study that made use of a new rating scale that examines a broader range of functioning in the home, rather than academic and behavioral parameters in the classroom.

Dr. Surman: ADHD can affect so many different domains of life function, and the pattern of impact is different for each individual case. You are targeting an area that is frustrating for many parents and we haven't had a tool to evaluate and measure dysfunction in before-school behavior. But how do you clinically assess function in other areas of a child's life?

Dr. Hammerness: We haven't studied this tool for other parts of the day, as yet. It was designed to tap the morning time, although the issue of struggling with routines around the home, of course, does not just apply to morning. When I am talking with parents and children about ADHD -- whether assessing how the treatment is working, or initially at the diagnostic stage, I often will divide the day into 3 periods, and assess each period individually. I ask questions that are oriented around (1) routines in the morning; then I will ask about (2) the school day; and then about (3) routines/activities after school/in the evening. You can also further break up the school day into morning time and afternoon time. Each period can result in different challenges and different issues for an individual child.

Dr. Surman: I am struck by the amount of research on stimulant interventions being presented at this year's APA meeting for children, adolescents, and adults with ADHD. We have fairly overwhelming data that stimulants are effective and reasonably safe in treating ADHD symptoms, but most of the studies run for a fairly short course.

Dr. Hammerness: We have a relative wealth of literature on pediatric ADHD when compared with any other topic in child psychiatry. However, I agree that we need studies looking at long-term outcomes based on behavioral ratings, as well as much more broad outcomes, including functional improvements on treatment, or functional difficulties over time during the course of ADHD. We still have much to learn.

What has been tremendously informative for me, as a pediatric clinician and an academician, is to see what ADHD looks like when patients are 20, 30, 40, 50, or 60 years old. The surge of clinical studies in adult ADHD over the past several years has provided us with that opportunity. Conversations with adults with ADHD have enabled me to understand the clinical course of ADHD, and share that knowledge with young families. This also then helps me to anticipate issues as youth become young adults. The time when adolescents leave home presents a huge challenge, for example; suddenly these adolescents are in college and they are expected, almost magically, to be adults, even in the face of great organizational challenges. Similar challenges can occur when entering the workforce.

Dr. Surman: A very recent follow-up study reports 8-year outcomes of the MTA.[2] Are the 8-year MTA outcomes consistent with your clinical experience of long-term treatment of pediatric ADHD?

Dr. Hammerness: It might be helpful to first acknowledge the editorial by Philip Hazell, which accompanied that report.[3] [Dr. Hazell is Professor of Psychological Medicine at University of Sydney, Australia.] He noted that future analysis will be looking at this sample more as a cohort over time, and less as treatment groups. The 8-year data found that only 32% of the children had taken medicine for more than 50% of the days in the previous year. Thus, this report is no longer presenting active "treatment" data. According to the authors, and follow this carefully, "To our knowledge, these findings are the first in the ADHD treatment literature to document a wide range of symptom and functioning outcomes, [and] the sustained absence of long-term effects (and I'm emphasizing this) of an initial period of randomly assigned treatment."

[Editor's note: For those who aren't familiar with the original study, the MTA compared 14 months of medication, medication plus behavioral intervention, and behavioral intervention alone. The participants have been followed naturalistically since that initial 14-month treatment period; some were still receiving treatment, some were not. The stated objective of this report was "to test whether ADHD symptom trajectory through 3 years predicts outcome in subsequent years; and to examine functioning level of the MTA adolescents relative to their non-ADHD peers."]

Dr. Surman: I agree that we should be very clear about what this study is. This follow-up reports long-term effects following an initial period of randomly assigned treatment. To date, we don't have prospective long-term treatment data for ADHD interventions, beyond the initial 14 months of the MTA study. As the authors of "The MTA at 8 Years"[2] note, the field would benefit from data comparing long-term impact of treatments in adolescents and young adults as well. Of course, we also know that adherence to these treatments is limited over the long term, and the field needs more study of the effect of not sticking with treatment.

But if a parent asks you about this report, a parent who may not understand that it is an evaluation of the initial treatment and, at best, its lingering effects, what do you say about what we know about long-term outcome, from your clinical experience, if we don't have academic research?

Dr. Hammerness: Based on my clinical experience, I talk about the constellation of symptoms that the child in question has, and my sense about what the course of those symptoms may be; for example, that some of the hyperactivity and impulsivity of early childhood may lessen, or may be internalized. Or, that a specific area of difficulty for some individuals with ADHD more than others is the problem of disorganization. Clinically, there is a group of children, adolescents, and adults who appear more disorganized than others; moreover, these deficits do not seem to be medication-responsive in the straightforward fashion as other symptoms of ADHD.

Therefore, with this area in mind, I emphasize organizational skill development at a very early age -- as part of this advice, I encourage families not to compensate for these organizational deficits. It is easy for families to get into the habit of packing the child's bags in the morning given common time constraints, but before you know it, suddenly the child is in 11th grade and has never packed his or her own bag. The extent to which practice and organizational skill development can yield significant and enduring change is not known at this time.

Dr. Surman: I would like to delve into the MTA 8-year follow-up a bit more.[2] To emphasize one point, the best predictor, or one of the best predictors that they found, of long-term prognosis over 8 years was baseline ADHD symptoms, and the early trajectory predicted what happened later. The authors also commented that the children who had behavioral and social demographic advantages had the best response to any of the treatments during the period of interest. This makes me think of how sensitive the function of many ADHD individuals is to environmental demands. Are there things you recommend to parents to optimize the ADHD-friendliness of their children's environments?

Dr. Hammerness: I think the most important tools a family/parent can provide involve organizational skill development. However, monitoring and communicating with school systems is also critical. With advances in technology and schools being online, in some ways there is a greater ease of communication, although I think that also can create some distance, compared with face-to-face conversations with teachers and school professionals. Whether online or in person, parents need to achieve a balance of being involved with and allowing for autonomy of their children. Parents ought to strive for the balance of being engaged, yet not too engaged, and should use the resources of schools and professionals to accomplish this heady task. Parents and patients should remain engaged in treatment over time, to allow for monitoring during periods of success as well as in periods of relative failure.

Dr. Surman: The clinician brings a significant clinical sensibility to educating parents and children about management of ADHD. The emphasis on clinical trials and shorter term drug trials may not be applicable to longer term outcomes and analyzing factors that predict long-term outcomes. What specific kinds of research will help to improve outcomes for children with ADHD?

Dr. Hammerness: We need to continue to study the natural course of ADHD and to search for possible moderators or mediators. Along the same lines, research must continue to examine response to medication over time as well as safety. As we are talking about treating children, adolescents, and adults for longer periods, we need to be looking at the longer term effects of the medications. I believe that there is renewed interest in the area of growth as a potential longer term adverse effect. The area that I am particularly interested in is the cardiovascular safety of these medications, and what variables moderate a patient's response to these medications.

Finally, the influence of comorbidities is critical. We frequently assess comorbid anxiety and mood disorders in our clinical and academic work, and it will be crucial to fold that piece into all these areas of study.

Dr. Surman: Aside from pharmacotherapy, and medical and mental health conditions and interventions, what do you think could help move the field forward in some of the supports that you have spoken about, such as skills building, and understanding interactions between the individual and the environment? I think these are more difficult to study, and I wonder if you share that feeling.

Dr. Hammerness: Yes, I certainly do. The effect of medication or therapy (eg, cognitive behavioral or organizational based) in persons with ADHD plus anxiety and mood comorbidity is very much an important area to study. This is quite a common clinical challenge, and we have little to guide us in terms of scientific research on this complex topic. Cognitive behavior models may be particularly useful when considering the common clinical complexity of the patient who, upon sitting down to do homework, or on the job, is immediately full of negative, depressive sorts of thoughts. One can imagine that it would be quite hard to get through to their attentional systems with these overwhelming cognitions and accompanying affect states.

Dr. Surman: Well, I want to thank you for your work, Paul. The field is inching toward a time when we will be able to give comprehensive, evidence-based clinical recommendations to parents and children about ADHD treatment. But I think the best treatment will always require a clinician who is willing to sit with a child and figure out who they are and how ADHD fits into the bigger picture of their lives. I appreciate your sensitivity to that complex challenge.

This activity is supported by an independent educational grant from Shire.