NIH Hosts Consensus Panel on ADHD
The National Institutes of Health panel (November,1998) reviewed existing research in the diagnosis and treatment of Attention Deficit Hyperactivity Disorder in order to identify areas of agreement among professionals and needs for additional research. The panel drafted an independent report summarizing what is known and highlighting key practice and research issues.
ADHD is a valid diagnosis, defining a cluster of characteristics (developmentally inappropriate attention, concentration, activity, distractibility, and impulsivity) , which can be reliably concluded by diagnostic interview methods. However, no data have identified an anatomical abnormality of the brain. There is no single diagnostic test.
ADHD impacts society. Children with ADHD have higher accident rates, and the medical costs of diagnosing and treating ADHD are often not covered by health insurance. Persons with ADHD often require a greater share of resources from schools, criminal justice, and social services to address co-existing conditions that lead to school failure, criminal activity and drug abuse.
While many treatments are mentioned, medications and psychosocial interventions have been the focus of research. Most clinical trials last about 3 months, so there is no information about long-term outcomes of medication with respect to academic achievement or social behaviors.
Among the stimulant medications (methylphenidate, dextroamphetamine, and pemoline) studied, few differences were found. In the short term, all improve the symptoms of ADHD and related aggression. But, stimulants do not impact all the problem behaviors, so children taking therapeutic doses still show a higher level of some behavior problems than children without ADHD and only modest improvement in learning or social skills.
Short-term study of antidepressants showed that desipramine improved ADHD symptoms over placebo according to teacher and parent ratings, but studies of imipramine are inconsistent.
Among the psychosocial interventions, cognitive-behavioral treatment (e.g., self-monitoring) does not seem to help the child. However, clinical behavior therapy, parent training in child management, and contingency strategies (e.g., reward system, timeout) show successes.
Recent work suggests that medication with systematic monitoring over a year may have more impact than intensive behavior interventions on basic ADHD symptoms. Combined treatment does little to further alter ADHD symptoms, but teacher/parents report improved social skills. Research is needed to assess if the combination might improve social and academic functioning with lower doses of medication.
While other interventions are acknowledged, there is no adequate research to support herbal or mineral or vitamin supplements, perceptual stimulation, or biofeedback. Research on ADHD, Inattentive type, which may be under-identified in girls is lacking. There are also no studies of the risks and benefits of psychostimulants through adolescence and into adult years.
The risks of stimulant medication use for ADHD are considered modest. Adverse reactions are usually related to dose or occur early in treatment and usually lessen with reduced dose or continued administration. Ultimate growth is not likely affected. Certain children are vulnerable to tics or movement disorders. Evidence exists of an association between ADHD diagnosis and an increased risk of drug abuse and cigarette smoking behaviors, but studies conflict as to whether the use of psychostimulants by children for ADHD increases or reduces their risk of future drug abuse. Co-existing conditions make research difficult.
Medical practices vary with respect to diagnosis, treatment and supervision. Some practitioners do not use structured questionnaires for parent and/or teacher input for diagnosis, and many physicians rely on parent input but do not request teacher input. Family practice physicians appear more likely to prescribe medication than pediatricians or psychiatrists. Primary care physicians are less likely than specialists to recognize co-existing conditions. A more consistent set of diagnostic procedures and practice guidelines are necessary.
Communication among those who diagnose the condition, those who treat the condition, and those who monitor change in school is generally poor or fragmented. Ideally, primary care providers would consult with a multidisciplinary school-based team, including parents, for diagnosis and be able to refer to mental health specialists such as those in school-based clinics.
Recommendations for integrated programs for diagnosis and treatment included teacher training to better recognize and provide special programs for students with ADHD and classroom strategies for more students to reduce the prevalence of referrals for ADHD assessment.
(Diagnosis and treatment of attention deficit hyperactivity disorder. NIH Consens Statement Online. 1998 Nov 16-18: In press. )
COMMENT: This extensive review of the state of art and science on ADHD is available at http://odp.od.nih.gov/consensus