Am Fam Physician. 1999;59(9):2645-2646
The National Institutes of Health (NIH) has issued a draft consensus development conference statement on the diagnosis and treatment of attention-deficit/hyperactivity disorder (ADHD). The conference that culminated in the draft statement was convened by the NIH to address the following questions about ADHD:
What is the scientific evidence to support ADHD as a disorder?
What is the impact of ADHD on individuals, families and society?
What are the effective treatments for ADHD?
What are the risks of the use of stimulant medication and other treatments?
What are the existing diagnostic and treatment practices, and what are the barriers to appropriate identification, evaluation and intervention?
What are the directions for future research?
The two- and one-half-day conference brought together experts in the field of relevant medical research and health care as well as representatives from the public. After listening to presentations and audience discussion at the conference, the panel, chaired by David J. Kupfer, M.D., Western Psychiatric Institute and Clinic, University of Pittsburgh, Pa., developed the statement.
The consensus statement can be found on the NIH Web site at http://odp.od.nih.gov/consensus/. The document can also be obtained from the NIH Consensus Program Information Center, P.O. Box 2577, Kensington, MD 20891; telephone: 888-644-2667.
ADHD is noted in the report to be the most commonly diagnosed behavioral disorder in childhood and represents a major public health problem. It is estimated that it affects 3 to 5 percent of all school-age children.
The report emphasizes that the impact of ADHD on the individuals with this disorder, their families and society is great. Children with ADHD cannot sit still and pay attention in class, and the negative consequences of such behavior have far-reaching and long-term consequences. The families of these children experience increased levels of parental frustration, marital discord and divorce. In addition, the medical care of these children is very expensive. Many children who have ADHD consume a large share of resources and attention from the health care system, criminal justice system, schools and other social service agencies. Decisions that have to be made in the care of these children often are made even more difficult by the conflicting reports in the media as to the benefits and adverse effects of treatments.
ADHD often does not present as an isolated disorder, and the panel believes that coexisting conditions may act as confounders in any research studies, which may explain why there are so many inconsistencies in research findings. The panel concluded that ADHD is a valid diagnosis and defines a cluster of maladjustive characteristics.
A wide variety of treatments have been used for children with ADHD, including various psychotropic medications, psychosocial treatment, dietary management, herbal and homeopathic treatments, biofeedback medication and perceptual stimulation/training. Research on these treatment strategies has centered primarily on medications and psychosocial interventions. Most of the clinical trials have been short term (only about three months). Overall, these studies have been positive for the use of stimulants and psychosocial treatments for ADHD. However, no information is available on the long-term outcome of these treatments. Combined medication and behavioral treatment may help social skills, and parents and teachers judged this treatment favorably.
Methylphenidate, dextroamphetamine and pemoline have been shown in trials to improve the core symptoms of ADHD, according to the report. However, stimulant treatments do not normalize the entire range of behavioral problems. Several short-term studies of antidepressants show that desipramine produces improvements over placebo in parent and teacher ratings of ADHD symptoms. Results from studies of imipramine are inconsistent. Data from the studies of other psychotropic medications are not extensive enough to allow for conclusions.
The following conclusions of the panel have been excerpted from the consensus statement:
Children with ADHD usually have pronounced difficulties and impairments resulting from the disorder across multiple settings. They also can experience long-term adverse effects on later academic, psychosocial and psychiatric outcomes.
Despite progress in the assessment, diagnosis and treatment of ADHD, this disorder and its treatment remain controversial in many public and private sectors. The major controversy regarding ADHD continues to be the use of psychostimulants for both short- and long-term treatment.
Although a consistent diagnostic test for ADHD does not exist, evidence supporting the validity of the disorder can be found. Further research will need to be conducted with respect to the dimensional aspect of ADHD, as well as the coexisting conditions present in both childhood and adult ADHD. An important research need is the investigation of standardized age- and gender-specific diagnostic criteria.
The impact of ADHD on individuals, families, schools and society is profound and necessitates immediate attention because a considerable share of resources from the health care system and various social service agencies is currently devoted to ADHD. Resource allocations based on better cost data leading to integrated care models need to be developed.
Effective treatments for ADHD have been evaluated primarily for the short term (only three months). These studies have included randomized clinical trials that have established the efficacy of stimulants and behavioral treatments for positive effects on the defining symptoms of ADHD and associated aggressiveness. Lack of consistent improvement beyond the core symptoms leads to the need for treatment strategies that use combined approaches. Currently, there is a paucity of data providing information on long-term treatment beyond 14 months. Although trials combining drugs and behavioral modalities are under way, conclusive recommendations concerning treatment for the long term cannot be made easily.
The risks of treatment, particularly the use of stimulant medication, are of considerable interest. Substantial evidence exists of wide variations in the use of psychostimulants across communities and among physicians, suggesting no consensus among practitioners regarding which patients should be treated with psychostimulants. As measured by attention/activity indexes, patients with varying levels and types of problems may benefit from stimulant therapy. However, there is no evidence regarding the appropriate ADHD diagnostic threshold above which the benefits of psychostimulant therapy outweigh the risks.
Existing diagnostic and treatment practices, in combination with the potential risks associated with medication, point to the need for improved awareness by the health service sector concerning an appropriate assessment, treatment and follow-up. A more consistent set of diagnostic procedures and practice guide is of utmost importance. Current barriers to evaluation and intervention exist across the health and education sectors. The cost barriers and lack of coverage preventing the appropriate diagnosis and treatment of ADHD and the lack of integration with special educational services represent considerable long-term cost for society. The lack of information and education about accessibility and affordabilty of services must be addressed.
After years of clinical research and experience with ADHD, knowledge about the cause or causes of ADHD remains speculative. Consequently, there are no strategies for the prevention of ADHD.
The panel believes that more research is needed to better define ADHD. Studies should focus on cognitive development and cognitive processing in ADHD. Brain imaging studies should be conducted before the initiation of medication, and individuals who have ADHD should be followed through young adulthood and into middle age. The impact of ADHD should also be determined. Additional studies are needed to develop a systematized treatment strategy. Greater attention should also be given to developing integrated programs for diagnosis and treatment.