Editorial 1

June 20, 2009

We begin this exciting adventure of The Elisabeth d'Ornano Association with the responsibility of trying to present its work to parents, educators and health professionals involved in the care and attention to children, adolescents and adults with ADHD. We believe that a fundamental part of that responsibility is reflected in our intention to keep those who believe in us well-informed. With a commitment to providing this information from reliable sources and including a monthly editorial in which we will bring you our own opinion, intending to offer an even greater value to this news section.

We cannot avoid starting with fantastic news that the majority of professionals dedicated to this field of Child and Adolescent Psychiatry hoped for. It is no other than the official confirmation of the coming inclusion in our national health system of this field that exists in virtually all countries around us. According to commentaries in the information from the Medical Journal (Diario Médico), this appears to be a reality that will be reflected in the positions offered for Internal Medicine Residents for the 2010-2011 year. This good news should have us congratulate all the individuals and institutions that have fought for this just cause for many years. However, given the importance of such an event, more than ever we must appeal to the responsibility of our leaders, to seek the important evaluation of the various people that have something to say about this area of study, starting with professionals who are devoted to it followed by parents' associations until we find the model that best fits the needs of patients and allows for a better transition for this new situation. With regard to this, it appears there will be a specialty in Child and Adolescent Psychiatry completely separated from General Psychiatry, which could be risky because it would mean going from not have a specialty to having a specialty that even the most developed countries have. For example, neither in the United Kingdom nor in the United States of America (USA), locations in which we have formed partnership of consultants with this association, is there is a specialty with such independence. In both cases, residents who specialize in pediatrics or general psychiatry have the option in their third or fourth year of studies of starting a "super-specialization” in Child and Adolescent Psychiatry for another two or three years. We make this observation due to the fact that some of us would not have chosen to specialize in children and adolescents having not known better, being once immersed in a specialty that is more “fundamental”. At the same time we would be ignoring the many commonalities that Child and Adolescent Psychiatry has with Adult Psychiatry and the need to understand mankind as a whole, its development and its pathology with continuity over time. Without wanting to establish a position on this issue yet, we do want to appeal to the wisdom that leads us to listen to all stakeholders and adopt a consensus model that allows interested professionals to engage in what motivates them most and take as a point of reference some model that have functioned properly with decades of tradition.

On another note, we cannot ignore the controversy that erupted in the U.S. after the publication of data from the MTA study, which has even had an impact in the general media, as illustrated by the article included from The Washington Post. This has even prompted concern by the American Academy of Child and Adolescent Psychiatry, one of the leading organizations in this field worldwide, which has published an editorial on the matter (also included in our news) in its monthly magazine and a letter on its website advising parents not to interrupt their children's medication without first consulting with medical specialists. This letter calls for caution not to rush to interpret some controversial results that require a detailed analysis by parents and experts from around the world. In the same fashion, from The Association Elisabeth d'Ornano, we want to clarify our position that not all cases of ADHD should be treated with medication and that this decision should be based on the specific characteristics of the disorder, the person affected and their families, the means of which the family has to take other measures that can help and, no doubt, on the opinion of a reliable expert who carries out an exhaustive examination of the individual and his or her surroundings. After reviewing all the information we have, we can state that medication can be clearly effective, especially in the early stages of the disorder, but the long-term effect of various drugs used to treat ADHD have not been shown. This may be because the drugs are not as effective as initially thought, or simply that sufficiently rigorous investigations to confirm this efficacy have not been carried out. The methodological problem is that, after the 14 months, the treatments were not followed in a rigorous and controlled fashion, thus the type of treatment received by patients initially assigned to each group was likely to be changed and each time was becoming more similar to treatment usually given in real life, and not like those in the study conditions. Thus the comparison between groups is probably unrealistic, it does not appear to be true that at 8 years there would be a group of patients treated only with medication or only with behavioral treatment alone or with an appropriate mix. The same applies to other treatments that have been suggested and which we mentioned in the recommendations for parents, teachers and health professionals. In this situation, we must appeal to the good work of the child and adolescent psychiatrists who already work in this country and the responsibility of parents, both of which essentially seek the best for their children and patients. There is no denying the evidence that pharmacological treatments of ADHD are associated with undesirable effects, as with most medications (including those from herbs or natural remedies) or with psychotherapies. In the case of methylphenidate, which does not appear to be particularly dangerous, it is true that it mainly can affect sleep and appetite in some patients, and long term may cause them to grow a few centimeters less or appear more tired with their daily activities. Only isolated cases have shown serious injury, and it seems that there are no serious effects on long-term use, although this remains to be studied further. But it is the responsibility of parents and professionals to know which ones are the cases where they should adjust the dose or even discontinue the medication on the basis of lack of efficacy or due to side effects, and perform a benefit and risk analysis that allows them to decide. Either way, the misunderstood "convenience" of using a pill as an almost magic treatment should be eradicated because no single treatment alone is able to solve a problem that has multiple causes and effects. Therefore, on the part of the association, we defend the individuality of each person with ADHD, taking into account each person’s personal circumstances, in order to help them from the perspectives of mental health and from his or her own family with the best treatment options available at different levels, without eliminating any a priori.

The risk of not treating ADHD adequately is reflected in the other articles that we present in this press review, even in the case of adults who suffer from ADHD that may also benefit from different therapeutic modalities. The possible relationship of sleep disorders with ADHD shows us the importance of an appropriate differential diagnosis by a professional; which is, as we see in other articles, in many cases is not entirely appropriate, especially when not performed by a specialist in psychiatry. The consequences of the disorder in academic results and the overall functioning of those who suffer from it, even in the possibility of future consumption of toxic substances, are troubling enough for us to become aware of the problem and get to work to try to deal with it properly.

And we are. Welcome and thanks for coming to us and choosing us in order to improve on this sensitive issue.

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