The aggressive and impulsive child: Innovations in assessment and treatment – A commentary

Children with behavioural, emotional and learning problems comprise a substantial proportion of a consultant paediatrician's practice. Along with this issue of Paediatrics & Child Health comes a supplement of papers from an industry-sponsored symposium on disruptive behaviour disorders. This commentary is intended to provide a context for interpreting the information in the supplement and applying it to paediatric practice. The supplement features several important messages about the assessment of attention deficit/hyperactivity disorder (ADHD) (1). A comprehensive assessment is needed to evaluate other possible problems. The Canadian Paediatric Society has developed guidelines to help practitioners assess and treat ADHD (2). The guidelines provide tools to assist the physician and include some of the measures mentioned in this commentary. Additional data-gathering tools in the Canadian Paediatric Society's manual, Children with School Problems (3), will help practitioners obtain the information needed to form the basis of an appropriate evaluation. The Multimodal Treatment Study of Children With Attention-Deficit/Hyperactivity Disorder (4) mentioned in the article by Jensen (5) supports the observation that stimulant medications are effective treatments for the core symptoms of ADHD. Some titration is necessary to discover the most appropriate medication, dosage and dosing schedule for an individual child. The resulting plan of care should include ongoing follow-up, dosage adjustments based on the timing and extent of a child's symptoms and linkage to other helpful supports. The Multimodal Treatment Study of Children With Attention-Deficit/Hyperactivity Disorder (6) included monthly meetings with the family to discuss the child's status and medication adjustments. Because the effects of the study have faded over time, some of the improvement may be related to the frequency of these meetings. Although children in the medication only and combined treatment groups had a greater reduction in symptoms, and two years later, they take higher doses of medication and are not as tall as the behaviour only and community control groups (7). The number of children using the medication has decreased in the two medication groups. Taking into account the long-term nature of the disorder, these observations suggest that aggressive management with medication alone may not lead to better long-term outcomes and frequent support from the paediatrician may be very important. Parents observe and are concerned about the side effects of medical intervention. A substantial proportion of families discontinue medication, often because they see little improvement and have observed side effects. Educating families about the disorder, the available options for treatment, proper expectations of improvement from these treatments and strategies for managing difficult behaviours, lead to improved satisfaction with medical treatment and improvement in the child's behaviour (8). The community paediatrician can often advocate the development of community resources to provide this information to families. Many children with ADHD experience social rejection in their schools and neighborhoods, which can lead to, or negatively affect, comorbid problems. There is also a group of children in which the issue of rebound (the worsening of symptoms as the medication wears off) is a particular problem. As middle childhood approaches, children want to avoid things that make them stand out as different, such as taking the medication at school. In older adolescents, the positive effects of medications on activities such as driving are important considerations. The use of long-acting medication is an appropriate consideration in these situations. Until recently, the sole choice for long-acting methylphenidate hydrochloride has been Ritalin SR (Novartis Pharmaceuticals, Canada), which is only available in a 20 mg dose. Often, it was only effective until midafternoon. Dextroamphetamine has also been available in a long-acting preparation, in two doses of 10 mg and 15 mg. This formulation appears to be effective for approximately 8 h. The addition of Concerta (Janssen-Ortho Inc, Canada) (9), which has a longer and more consistent duration of therapeutic effect, and Adderall XR (Shire BioChem Inc, Canada) (10), which has multiple dosing options and can be sprinkled on food, has presented new choices and advantages to the medical management of ADHD. The immediate release methylphenidate hydrochloride component of Concerta is 4 mg, 8 mg and 12 mg in the 18 mg, 36 mg and 54 mg tablets, respectively. Some children may need more than this, so additional regular release medication may also be necessary. In addition, a change to Concerta may necessitate an increase in the total daily dose of methylphenidate hydrochloride. This may cause discomfort for the family and the prescribing physician. At the same time, Concerta may be beneficial when the ability to effectively perform an activity (eg, driving) is important later on in the day (11). There is evidence of an illegal market for stimulant medications in schools and the community (12). It is very difficult to extract the methylphenidate hydrochloride in Concerta (13), leading to a lower probability of abuse of this product. This is an important consideration in the high school environment. There is also the issue of cost. Public health authorities are reluctant to approve funding for sustained release products in cases where regular release medications provide similar therapeutic effect. In such situations, one of the newer preparations may well be the most appropriate and effective therapeutic option. Advocacy for funding of this therapy is needed. The issues raised regarding the treatment of other disruptive behaviours (14) are very complex. Improvement in both oppositional and aggressive behaviour can occur with the use of stimulant medication when ADHD is also present (15). Positive parenting strategies designed for parents of children with difficult behaviour can also lead to improvement. Other social factors contribute to the onset and evolution of aggressive and oppositional behaviour, and other conduct problems. This requires multifaceted assessment and so-called multimodal treatment in children who have complex comorbid problems (16). Linkage to available mental health support resources, including child psychiatrists, are important. The use of multiple medications for these difficult situations is not unusual and is practiced by psychiatrists and some paediatricians responsible for the supervision of medical therapy for this population. Some children with oppositional and aggressive behaviour are candidates for medical therapy (in addition to stimulants). In these situations, there is evidence that risperidone can be effective (17). Concerns have emerged about the issue of weight gain as a side effect, and its associated health and psychosocial effects. In adults, this has led to physicians recommending weight management programs for patients and monitoring for problems with glucose metabolism and lipids (18). It is prudent to consider these maneuvers, particularly with prolonged use, although there is limited research to date in children and youth (19). Community paediatricians are an important resource in the support of children with behavioural and learning disorders. Their understanding that these problems are long-term and require treatment adjustment with the child's ongoing health and development, places them in a position to make recommendations for the most appropriate therapy based on the needs of the child and family.

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