Treatment Options for Attention Deficit Hyperactivity Disorder
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Treatment Options for Attention Deficit Hyperactivity Disorder

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ADHD is the most commonly studied and diagnosed psychiatric disorder in children, affecting about 3 to 5 percent of children globally and diagnosed in about 2 to 16 percent of school-aged children. ...

ADHD is the most commonly studied and diagnosed psychiatric disorder in children, affecting about 3 to 5 percent of children globally and diagnosed in about 2 to 16 percent of school-aged children. It is a chronic disorder with 30 to 50 percent of those individuals diagnosed in childhood continuing to have symptoms into adulthood. Adolescents and adults with ADHD tend to develop coping mechanisms to compensate for some or all of their impairments. It is estimated that 4.7 percent of American adults live with ADHD.

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  • Treatment Options for Attention Deficit Hyperactivity DisorderThis slide set is based on a comparative effectiveness review (CER) titled Attention Deficit Hyperactivity Disorder: Effectiveness of Treatment in At-Risk Preschoolers; Long-Term Effectiveness in All Ages; and Variability in Prevalence, Diagnosis, and Treatment, which was developed by the McMaster University Evidence-based Practice Center for the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD under Contract No. MME 2202 290-02-0020 and is available online at www.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.CERs are comprehensive systematic reviews of the literature that usually compare two or more types of treatment with usual care for the same disease. This CER assessed the existing body of evidence on the efficacy and safety of different interventions used to treat attention deficit hyperactivity disorder (ADHD). The literature included in this review was identified in searches for trials and studies published through May 2010.Reference:Charach A, Dashti B, Carson P, et al. Attention Deficit Hyperactivity Disorder: Effectiveness of Treatment in At-Risk Preschoolers; Long-Term Effectiveness in All Ages; and Variability in Prevalence, Diagnosis, and Treatment. Comparative Effectiveness Review No. 44 (Prepared by McMaster University Evidence-based Practice Center under Contract No. MME 2202 290-02-0020). Rockville, MD: Agency for Healthcare Research and Quality; October 2011. AHRQ Publication No. 11(12)-EHC003-EF. Available at www.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Outline of MaterialThe material in this presentation covers the results and conclusions from a systematic CER review entitled Attention Deficit Hyperactivity Disorder: Effectiveness of Treatment in At-Risk Preschoolers; Long-Term Effectiveness in All Ages; and Variability in Prevalence, Diagnosis, and Treatment. It begins with an introduction to ADHD and treatment options. It also covers: methods used to plan and execute the systematic review; clinically important questions the review sought to answer; evidence-based conclusions about the effectiveness of ADHD treatments for preschoolers and individuals 6 years of age and older; unrated findings on adverse effects of ADHD treatments; unrated conclusions on variability in the prevalence, clinical identification, and treatment of ADHD associated with potential moderating factors; gaps in knowledge; and future research needs uncovered by the systematic review.Reference:Charach A, Dashti B, Carson P, et al. Attention Deficit Hyperactivity Disorder: Effectiveness of Treatment in At-Risk Preschoolers; Long-Term Effectiveness in All Ages; and Variability in Prevalence, Diagnosis, and Treatment. Comparative Effectiveness Review No. 44 (Prepared by McMaster University Evidence-based Practice Center under Contract No. MME 2202 290-02-0020). Rockville, MD: Agency for Healthcare Research and Quality; October 2011. AHRQ Publication No. 11(12)-EHC003-EF. Available at www.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Background: Characteristics of ADHD (1 of 3)ADHD is a condition characterized by inattention, hyperactivity, and impulsivity. ADHD affects children of all ages, and population studies indicate that about 5% of children worldwide show impaired levels of attention and hyperactivity. There are three subtypes of ADHD: 1) predominantly inattentive, 2) predominantly hyperactive-impulsive, and 3) combined inattentive and hyperactive. Boys are classified with ADHD about twice as frequently as girls, and younger children about twice as frequently as adolescents.Reference:Charach A, Dashti B, Carson P, et al. Attention Deficit Hyperactivity Disorder: Effectiveness of Treatment in At-Risk Preschoolers; Long-Term Effectiveness in All Ages; and Variability in Prevalence, Diagnosis, and Treatment. Comparative Effectiveness Review No. 44 (Prepared by McMaster University Evidence-based Practice Center under Contract No. MME 2202 290-02-0020). Rockville, MD: Agency for Healthcare Research and Quality; October 2011. AHRQ Publication No. 11(12)-EHC003-EF. Available at www.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Background: Characteristics of ADHD (2 of 3)Clinically significant ADHD is often associated with concurrent defiant and disruptive behaviors, temper tantrums, anxiety, low self-esteem, and learning disabilities. Symptoms are clinically significant when they interfere with academic and behavioral functioning. ADHD symptoms may also disrupt family and peer relationships. ADHD is most commonly identified and treated in elementary school, around the ages 7 to 9 years, but can begin before children enter school. There is increasing interest in identifying children who show signs of ADHD at a very young age so they can be treated as early as possible and thereby diminish social and academic repercussions.Reference:Charach A, Dashti B, Carson P, et al. Attention Deficit Hyperactivity Disorder: Effectiveness of Treatment in At-Risk Preschoolers; Long-Term Effectiveness in All Ages; and Variability in Prevalence, Diagnosis, and Treatment. Comparative Effectiveness Review No. 44 (Prepared by McMaster University Evidence-based Practice Center under Contract No. MME 2202 290-02-0020). Rockville, MD: Agency for Healthcare Research and Quality; October 2011. AHRQ Publication No. 11(12)-EHC003-EF. Available at www.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Background: Characteristics of ADHD (3 of 3)Overall, levels of symptoms of hyperactivity and impulsivity decrease with age; however, many children with ADHD continue to show impairment relative to same-age peers throughout adolescence and into adulthood.Reference:Charach A, Dashti B, Carson P, et al. Attention Deficit Hyperactivity Disorder: Effectiveness of Treatment in At-Risk Preschoolers; Long-Term Effectiveness in All Ages; and Variability in Prevalence, Diagnosis, and Treatment. Comparative Effectiveness Review No. 44 (Prepared by McMaster University Evidence-based Practice Center under Contract No. MME 2202 290-02-0020). Rockville, MD: Agency for Healthcare Research and Quality; October 2011. AHRQ Publication No. 11(12)-EHC003-EF. Available at www.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Background: ADHD InterventionsInterventions for ADHD include a range of pharmacologic and nonpharmacologic options. Psychostimulants and nonstimulant medications are often prescribed. Children with ADHD and their families may also receive nonspecific psychosocial support, counseling, and advice through standardized programs for parents and children. Children with ADHD may receive academic tutoring and coaching, both within and outside of school settings. Complementary and alternative medicine options, including dietary supplements, are also available but are not covered in this review. Few ADHD interventions have been systematically evaluated, and fewer still have been examined for their long-term effectiveness.Reference:Charach A, Dashti B, Carson P, et al. Attention Deficit Hyperactivity Disorder: Effectiveness of Treatment in At-Risk Preschoolers; Long-Term Effectiveness in All Ages; and Variability in Prevalence, Diagnosis, and Treatment. Comparative Effectiveness Review No. 44 (Prepared by McMaster University Evidence-based Practice Center under Contract No. MME 2202 290-02-0020). Rockville, MD: Agency for Healthcare Research and Quality; October 2011. AHRQ Publication No. 11(12)-EHC003-EF. Available at www.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Background: ADHD Medications (1 of 2)Psychostimulant medications (mixed amphetamine salts, dextroamphetamine, lisdexamfetamine, and methylphenidate) are prescribed to treat ADHD. These generic medications go by different brand names and come in different preparations.Reference:Charach A, Dashti B, Carson P, et al. Attention Deficit Hyperactivity Disorder: Effectiveness of Treatment in At-Risk Preschoolers; Long-Term Effectiveness in All Ages; and Variability in Prevalence, Diagnosis, and Treatment. Comparative Effectiveness Review No. 44 (Prepared by McMaster University Evidence-based Practice Center under Contract No. MME 2202 290-02-0020). Rockville, MD: Agency for Healthcare Research and Quality; October 2011. AHRQ Publication No. 11(12)-EHC003-EF. Available at www.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Background: ADHD Medications (2 of 2)Some nonstimulant medications are also prescribed to treat ADHD. These include atomoxetine (Strattera®), clonidine hydrochloride (Kapvay®), and guanfacine ER (Intuniv®). Clonidine hydrochloride (Kapvay®) was not included in this report.Reference:Charach A, Dashti B, Carson P, et al. Attention Deficit Hyperactivity Disorder: Effectiveness of Treatment in At-Risk Preschoolers; Long-Term Effectiveness in All Ages; and Variability in Prevalence, Diagnosis, and Treatment. Comparative Effectiveness Review No. 44 (Prepared by McMaster University Evidence-based Practice Center under Contract No. MME 2202 290-02-0020). Rockville, MD: Agency for Healthcare Research and Quality; October 2011. AHRQ Publication No. 11(12)-EHC003-EF. Available at www.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Background: Behavior Training InterventionsBehavior training for parents is often suggested as an intervention for parents of children with ADHD. These programs are designed to help parents strengthen their bond with their child and manage their child’s problematic behavior with more effective discipline strategies using rewards and nonpunitive consequences. An important aspect of each program is to promote a positive and caring relationship between parents and their child. Each program also includes educational components regarding childhood behavior problems and common developmental issues. Programs may include coaching or consultation to support parents’ efforts.There are four widely disseminated standardized programs of behavior training interventions for parents developed by separate research groups in the past 25 years, although many others exist: Positive Parenting Program (Triple P), the Incredible Years Parenting Program (IYPP), Parent-Child Interaction Therapy (PCIT), and the New Forest Parenting Program (NFPP). While each of these programs has its own specific features, they all share common therapeutic components and are documented in manuals to ensure intervention integrity when disseminated.Reference:Charach A, Dashti B, Carson P, et al. Attention Deficit Hyperactivity Disorder: Effectiveness of Treatment in At-Risk Preschoolers; Long-Term Effectiveness in All Ages; and Variability in Prevalence, Diagnosis, and Treatment. Comparative Effectiveness Review No. 44 (Prepared by McMaster University Evidence-based Practice Center under Contract No. MME 2202 290-02-0020). Rockville, MD: Agency for Healthcare Research and Quality; October 2011. AHRQ Publication No. 11(12)-EHC003-EF. Available at www.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Agency for Healthcare Research and Quality (AHRQ) Comparative Effectiveness Review (CER) DevelopmentTopics are nominated through a public process, which includes submissions from health care professionals, professional organizations, the private sector, policymakers, members of the public, and others. A systematic review of all relevant clinical studies is conducted by independent researchers, funded by AHRQ, to synthesize the evidence in a report summarizing what is known and not known about the select clinical issue. The research questions and the results of the report are subject to expert input, peer review, and public comment. The results of these reviews are summarized into Clinician Research Summaries and Consumer Research Summaries for use in decisionmaking and in discussions with patients. The summaries and the full report, with references for included and excluded studies, are available at www.effectivehealthcare.ahrq.gov.Reference:Charach A, Dashti B, Carson P, et al. Attention Deficit Hyperactivity Disorder: Effectiveness of Treatment in At-Risk Preschoolers; Long-Term Effectiveness in All Ages; and Variability in Prevalence, Diagnosis, and Treatment. Comparative Effectiveness Review No. 44 (Prepared by McMaster University Evidence-based Practice Center under Contract No. MME 2202 290-02-0020). Rockville, MD: Agency for Healthcare Research and Quality; October 2011. AHRQ Publication No. 11(12)-EHC003-EF. Available at www.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Clinical Questions Addressed by the CERIn preparing the report on which this continuing medical education (CME) activity is based, the authors aimed to answer the three Key Questions (KQs) listed below.KQ 1: Among children younger than 6 years of age with ADHD or disruptive behavior disorder (DBD), what are the effectiveness and adverse event outcomes following treatment?KQ2: Among people 6 years of age or older with ADHD, what are the effectiveness and adverse event outcomes following 12 months or more of any combination of followup or treatment, including, but not limited to, 12 months or more of continuous treatment?KQ3: How do a) underlying prevalence of ADHD and b) rates of diagnosis (clinical identification) and treatment for ADHD vary by geography, time period, provider type, and socioeconomic characteristics?Reference:Charach A, Dashti B, Carson P, et al. Attention Deficit Hyperactivity Disorder: Effectiveness of Treatment in At-Risk Preschoolers; Long-Term Effectiveness in All Ages; and Variability in Prevalence, Diagnosis, and Treatment. Comparative Effectiveness Review No. 44 (Prepared by McMaster University Evidence-based Practice Center under Contract No. MME 2202 290-02-0020). Rockville, MD: Agency for Healthcare Research and Quality; October 2011. AHRQ Publication No. 11(12)-EHC003-EF. Available at www.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Rating the Strength of Evidence From the CERThroughout this slide set, strength of evidence ratings are assigned to findings of the report. Strength of evidence is typically assigned to reviews of medical treatments after assessing four domains: risk of bias, consistency, directness, and precision. Although these categories were developed for assessing the strength of treatment studies, the domains apply also to studies of prevalence and screening. Available evidence for each KQ was assessed for each of these four domains; the domains were combined qualitatively to develop the strength of evidence for each KQ.Reference:Charach A, Dashti B, Carson P, et al. Attention Deficit Hyperactivity Disorder: Effectiveness of Treatment in At-Risk Preschoolers; Long-Term Effectiveness in All Ages; and Variability in Prevalence, Diagnosis, and Treatment. Comparative Effectiveness Review No. 44 (Prepared by McMaster University Evidence-based Practice Center under Contract No. MME 2202 290-02-0020). Rockville, MD: Agency for Healthcare Research and Quality; October 2011. AHRQ Publication No. 11(12)-EHC003-EF. Available at www.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Effectiveness of ADHD or DBD Interventions in Children Under 6 Years of Age (1 of 2)Twenty-eight randomized controlled trials (RCTs) show that parental behavior training is an efficacious treatment for preschoolers with disruptive behavior disorder; eight of these studies documented improvement specifically in ADHD symptoms. Long-term extension followup studies for the RCTs suggest that the benefits are maintained for at least 6 months and up to 2 years in some studies. Parents who attend more parental behavior training sessions see more improvement in their child’s behavior.Strength of evidence: HighThere are only a few short-term studies examining psychostimulant use in preschoolers, most with small sample sizes. One RCT with a more robust sample size offered excellent evidence that methylphenidate (MPH) is both efficacious and generally safe for treatment of ADHD symptoms. However, there has been limited long-term followup in preschoolers beyond 12 months.Strength of evidence: LowReference:Charach A, Dashti B, Carson P, et al. Attention Deficit Hyperactivity Disorder: Effectiveness of Treatment in At-Risk Preschoolers; Long-Term Effectiveness in All Ages; and Variability in Prevalence, Diagnosis, and Treatment. Comparative Effectiveness Review No. 44 (Prepared by McMaster University Evidence-based Practice Center under Contract No. MME 2202 290-02-0020). Rockville, MD: Agency for Healthcare Research and Quality; October 2011. AHRQ Publication No. 11(12)-EHC003-EF. Available at www.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Effectiveness of ADHD or DBD Interventions in Children Under 6 Years of Age (2 of 2)Evidence is insufficient to know if there is an additional benefit to combining different treatments.Strength of evidence: InsufficientIt should be noted that where there is socioeconomic burden, a school-based intervention appears to be the primary beneficial intervention. Benefits, however, diminished over 2 years. This appears to be related to lack of parental engagement and attendance at sessions.Strength of evidence: InsufficientReference:Charach A, Dashti B, Carson P, et al. Attention Deficit Hyperactivity Disorder: Effectiveness of Treatment in At-Risk Preschoolers; Long-Term Effectiveness in All Ages; and Variability in Prevalence, Diagnosis, and Treatment. Comparative Effectiveness Review No. 44 (Prepared by McMaster University Evidence-based Practice Center under Contract No. MME 2202 290-02-0020). Rockville, MD: Agency for Healthcare Research and Quality; October 2011. AHRQ Publication No. 11(12)-EHC003-EF. Available at www.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Long-Term (>1 Year) Effectiveness of ADHD Interventions in People 6 Years of Age or Older: PharmacologicPsychostimulants provide control of ADHD symptoms and are generally well tolerated for months to years at a time. Overall, the benefits and safety of MPH for symptom control and general functioning are clearly documented, primarily for boys 7 to 9 years of age at initiation with the combined type of ADHD. There are many similarities between MPH immediate release and other preparations of psychostimulants, both in terms of efficacy and in the side effect profile. Therefore, many researchers and clinicians assume all psychostimulants are effective and safe for extended periods of time; however, the documentation for this assertion is not yet robust.Strength of evidence: LowLong-term extension trials show that ATX is both safe and effective for treating ADHD symptoms in children and teens over a period of 12 months. These studies offer direct comparison with placebo for the examination of relapse prevention, offering clear evidence of effectiveness in children and teens.Strength of evidence: LowOnly one study of extended-release guanfacine (GXR) monotherapy is available. It reports reduced ADHD symptoms and global improvement with GXR, although less than a fifth of participants completed 12 months of treatment. Extension trials suggest that while GXR appears to be an effective treatment, high rates of adverse effects interfere with its use. Thus GXR does not appear to be as well accepted as a long-term treatment for ADHD in children as either psychostimulants or ATX. More studies are needed to permit an evidence-based conclusion about the long-term effectiveness of GXR.Strength of evidence: InsufficientReference:Charach A, Dashti B, Carson P, et al. Attention Deficit Hyperactivity Disorder: Effectiveness of Treatment in At-Risk Preschoolers; Long-Term Effectiveness in All Ages; and Variability in Prevalence, Diagnosis, and Treatment. Comparative Effectiveness Review No. 44 (Prepared by McMaster University Evidence-based Practice Center under Contract No. MME 2202 290-02-0020). Rockville, MD: Agency for Healthcare Research and Quality; October 2011. AHRQ Publication No. 11(12)-EHC003-EF. Available at www.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Long-term (>1 Year) Effectiveness of ADHD Interventions in People 6 Years of Age or Older: NonpharmacologicThe literature describing behavioral or psychosocial treatments commonly focuses on these interventions for outcomes of disruptive behavior, not ADHD symptoms, even though these are commonly comorbid conditions. Therefore, few long-term extension studies lasting 12 or more months are available, and evidence is insufficient to know if behavioral or psychosocial treatment alone is an effective long-term treatment option for children with ADHD.Strength of evidence: InsufficientThere are few comparative school-based intervention studies lasting 12 months or longer, and information from those that are available is mixed. Thus there is not enough evidence to know if school-based interventions are an effective long-term treatment option for children with ADHD. However, one good-quality study and its extension showed that school-based programs to enhance academic skills are effective in improving achievement scores in multiple domains. There is also insufficient evidence to draw conclusions about the long-term effectiveness of parental behavior training interventions for children 6 years of age or older with ADHD.Strength of evidence: InsufficientReference:Charach A, Dashti B, Carson P, et al. Attention Deficit Hyperactivity Disorder: Effectiveness of Treatment in At-Risk Preschoolers; Long-Term Effectiveness in All Ages; and Variability in Prevalence, Diagnosis, and Treatment. Comparative Effectiveness Review No. 44 (Prepared by McMaster University Evidence-based Practice Center under Contract No. MME 2202 290-02-0020). Rockville, MD: Agency for Healthcare Research and Quality; October 2011. AHRQ Publication No. 11(12)-EHC003-EF. Available at www.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Long-term (>1 Year) Effectiveness of ADHD Interventions in People 6 Years of Age or Older: Combined TreatmentsTwo large RCTs and one smaller study found that both psychostimulant medication alone and combined medication and behavioral treatment are effective in treating ADHD plus oppositional defiant disorder (ODD) symptoms in children. One of the large RCTs clearly demonstrated that MPH improved ADHD and ODD symptoms and overall functioning alone or in combination with psychosocial/behavioral interventions for 12 months up to 24 months.Strength of evidence: LowReference:Charach A, Dashti B, Carson P, et al. Attention Deficit Hyperactivity Disorder: Effectiveness of Treatment in At-Risk Preschoolers; Long-Term Effectiveness in All Ages; and Variability in Prevalence, Diagnosis, and Treatment. Comparative Effectiveness Review No. 44 (Prepared by McMaster University Evidence-based Practice Center under Contract No. MME 2202 290-02-0020). Rockville, MD: Agency for Healthcare Research and Quality; October 2011. AHRQ Publication No. 11(12)-EHC003-EF. Available at www.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Adverse Effects (1 of 3)Although not critically evaluated within the report, general research on adverse effects associated with ADHD treatments suggests the following:Psychostimulants and ATX may cause insomnia, appetite loss, tiredness, social withdrawal, and abdominal pain.Psychostimulants and ATX may also cause a modest increase in average blood pressure and average heart rate in some children and adolescents.Children or adolescents taking ATX may be more likely to think about suicide than those who do not take it.Common side effects of psychostimulants and ATX include insomnia, appetite loss, tiredness, social withdrawal, and abdominal pain. Psychostimulants and ATX may also cause a modest increase in average blood pressure and average heart rate in some children and adolescents. Children or adolescents taking ATX may be more likely to think about suicide than children who do not take it.Reference:Charach A, Dashti B, Carson P, et al. Attention Deficit Hyperactivity Disorder: Effectiveness of Treatment in At-Risk Preschoolers; Long-Term Effectiveness in All Ages; and Variability in Prevalence, Diagnosis, and Treatment. Comparative Effectiveness Review No. 44 (Prepared by McMaster University Evidence-based Practice Center under Contract No. MME 2202 290-02-0020). Rockville, MD: Agency for Healthcare Research and Quality; October 2011. AHRQ Publication No. 11(12)-EHC003-EF. Available at www.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Adverse Effects (2 of 3)Overall, more adverse effects were reported in preschoolers than in primary school children. Moodiness and irritability often led to discontinuation of treatment with MPH. ADHD medications appear to have a small but distinct dose-related impact on growth rates in children. Some studies found that although children taking ADHD medications appear to have diminished growth rates, they may eventually catch up on their growth over time. Safety investigations from observational studies and administrative databases did not provide conclusive evidence for cardiovascular or cerebrovascular adverse effects.Reference:Charach A, Dashti B, Carson P, et al. Attention Deficit Hyperactivity Disorder: Effectiveness of Treatment in At-Risk Preschoolers; Long-Term Effectiveness in All Ages; and Variability in Prevalence, Diagnosis, and Treatment. Comparative Effectiveness Review No. 44 (Prepared by McMaster University Evidence-based Practice Center under Contract No. MME 2202 290-02-0020). Rockville, MD: Agency for Healthcare Research and Quality; October 2011. AHRQ Publication No. 11(12)-EHC003-EF. Available at www.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Adverse Effects (3 of 3)GXR was not well tolerated in studies, with less than 20 percent of participants completing the studies at 12 months. Adverse effects include somnolence or sedation, fatigue, headache, and possible weight gain. Abnormal or worsening electrocardiographic changes judged clinically significant in 1 percent of patients suggest that monitoring of cardiac status is indicated.Reference:Charach A, Dashti B, Carson P, et al. Attention Deficit Hyperactivity Disorder: Effectiveness of Treatment in At-Risk Preschoolers; Long-Term Effectiveness in All Ages; and Variability in Prevalence, Diagnosis, and Treatment. Comparative Effectiveness Review No. 44 (Prepared by McMaster University Evidence-based Practice Center under Contract No. MME 2202 290-02-0020). Rockville, MD: Agency for Healthcare Research and Quality; October 2011. AHRQ Publication No. 11(12)-EHC003-EF. Available at www.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Variability in Prevalence, Clinical Identification, and Treatment of ADHD in Children (1 of 5)The information in this slide lists conclusions on the variability in prevalence, diagnosis, and treatment of ADHD in children associated with potential moderating factors. For these conclusions, the literature was searched using the methodology of a systematic review; however, the selection of papers for inclusion was not subject to the same constraints as the rest of the report. Other relevant papers were added via peer review feedback. These findings were included to provide context, and any studies considered pertinent to the topic of variability in ADHD prevalence, diagnosis, and treatment were included.Location Cultural differences influence how ADHD is understood and treated in different countries. After taking into account differences in research methodologies between countries, the underlying prevalence does not appear to vary much among countries. Rates of diagnosis vary considerably due to cultural context, access to local health care services, and providers available in the area. There are significant regional variations in clinical identification across the United States. Rates of treatment vary considerably due to location and access to health care providers—internationally, regionally, and even within the same community.Reference:Charach A, Dashti B, Carson P, et al. Attention Deficit Hyperactivity Disorder: Effectiveness of Treatment in At-Risk Preschoolers; Long-Term Effectiveness in All Ages; and Variability in Prevalence, Diagnosis, and Treatment. Comparative Effectiveness Review No. 44 (Prepared by McMaster University Evidence-based Practice Center under Contract No. MME 2202 290-02-0020). Rockville, MD: Agency for Healthcare Research and Quality; October 2011. AHRQ Publication No. 11(12)-EHC003-EF. Available at www.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Variability in Prevalence, Clinical Identification, and Treatment of ADHD in Children (2 of 5)The information in this slide lists conclusions on the variability in prevalence, diagnosis, and treatment of ADHD in children associated with potential moderating factors. For these conclusions, the literature was searched using the methodology of a systematic review; however, the selection of papers for inclusion was not subject to the same constraints as the rest of the report. Other relevant papers were added via peer review feedback. These findings were included to provide context, and any studies considered pertinent to the topic of variability in ADHD prevalence, diagnosis, and treatment were included.Service Provider Providers vary in their level of expertise in diagnosing ADHD, as well as in familiarity with screening instruments and classification systems.Informant Rates of diagnosis vary considerably due to cultural context. Some ethnicities are more likely to seek help or accept the diagnosis than others. The sociocultural experience of the parent or teacher informant may influence interpretation and reporting of behaviors, willingness and persistence in seeking professional help, and/or acceptance of treatment modalities.Reference:Charach A, Dashti B, Carson P, et al. Attention Deficit Hyperactivity Disorder: Effectiveness of Treatment in At-Risk Preschoolers; Long-Term Effectiveness in All Ages; and Variability in Prevalence, Diagnosis, and Treatment. Comparative Effectiveness Review No. 44 (Prepared by McMaster University Evidence-based Practice Center under Contract No. MME 2202 290-02-0020). Rockville, MD: Agency for Healthcare Research and Quality; October 2011. AHRQ Publication No. 11(12)-EHC003-EF. Available at www.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Variability in Prevalence, Clinical Identification, and Treatment of ADHD in Children (3 of 5)The information in this slide lists conclusions on the variability in prevalence, diagnosis, and treatment of ADHD in children associated with potential moderating factors. For these conclusions, the literature was searched using the methodology of a systematic review; however, the selection of papers for inclusion was not subject to the same constraints as the rest of the report. Other relevant papers were added via peer review feedback. These findings were included to provide context, and any studies considered pertinent to the topic of variability in ADHD prevalence, diagnosis, and treatment were included.Time Period Since being identified as a clinical entity in 1902, the prevalence of identified ADHD cases has increased. This is partially due to increased knowledge about ADHD. It is also partially due to changes in the definition of who can identify a child as having ADHD (parents and teachers are becoming informants), changes in screening tests, and changes in diagnostic categories and classification systems over time. The medical use of MPH or drug treatment of ADHD has increased steadily since the early 1980s. As an indicator of trends in treatment, the International Narcotics Control Board reported that medical use of MPH in the United States increased 77 percent from 2004 to 2008.Reference:Charach A, Dashti B, Carson P, et al. Attention Deficit Hyperactivity Disorder: Effectiveness of Treatment in At-Risk Preschoolers; Long-Term Effectiveness in All Ages; and Variability in Prevalence, Diagnosis, and Treatment. Comparative Effectiveness Review No. 44 (Prepared by McMaster University Evidence-based Practice Center under Contract No. MME 2202 290-02-0020). Rockville, MD: Agency for Healthcare Research and Quality; October 2011. AHRQ Publication No. 11(12)-EHC003-EF. Available at www.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Variability in Prevalence, Clinical Identification, and Treatment of ADHD in Children (4 of 5)The information in this slide lists conclusions on the variability in prevalence, diagnosis, and treatment of ADHD in children associated with potential moderating factors. For these conclusions, the literature was searched using the methodology of a systematic review; however, the selection of papers for inclusion was not subject to the same constraints as the rest of the report. Other relevant papers were added via peer review feedback. These findings were included to provide context, and any studies considered pertinent to the topic of variability in ADHD prevalence, diagnosis, and treatment were included.Socioeconomic Status Rates of diagnosis vary considerably due to cultural context. Some ethnicities are more likely to seek help or accept the diagnosis than others. The sociocultural experience of the parent or teacher informant may influence interpretation and reporting of behaviors, willingness and persistence in seeking professional help, and/or acceptance of treatment modalities.Sex Most studies found the prevalence of ADHD is greater in boys than in girls. There are few comparative data examining rates of treatment by sex in children diagnosed with ADHD.Reference:Charach A, Dashti B, Carson P, et al. Attention Deficit Hyperactivity Disorder: Effectiveness of Treatment in At-Risk Preschoolers; Long-Term Effectiveness in All Ages; and Variability in Prevalence, Diagnosis, and Treatment. Comparative Effectiveness Review No. 44 (Prepared by McMaster University Evidence-based Practice Center under Contract No. MME 2202 290-02-0020). Rockville, MD: Agency for Healthcare Research and Quality; October 2011. AHRQ Publication No. 11(12)-EHC003-EF. Available at www.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Variability in Prevalence, Clinical Identification, and Treatment of ADHD in Children (5 of 5)The information in this slide lists conclusions on the variability in prevalence, diagnosis, and treatment of ADHD in children associated with potential moderating factors. For these conclusions, the literature was searched using the methodology of a systematic review; however, the selection of papers for inclusion was not subject to the same constraints as the rest of the report. Other relevant papers were added via peer review feedback. These findings were included to provide context, and any studies considered pertinent to the topic of variability in ADHD prevalence, diagnosis, and treatment were included.Age Children ages 5 to 10 years appear to have the highest prevalence of ADHD. Elementary school children are identified as having ADHD more frequently than older children. Medication treatment prevalence is higher for elementary school children than for adolescents or adults.Reference:Charach A, Dashti B, Carson P, et al. Attention Deficit Hyperactivity Disorder: Effectiveness of Treatment in At-Risk Preschoolers; Long-Term Effectiveness in All Ages; and Variability in Prevalence, Diagnosis, and Treatment. Comparative Effectiveness Review No. 44 (Prepared by McMaster University Evidence-based Practice Center under Contract No. MME 2202 290-02-0020). Rockville, MD: Agency for Healthcare Research and Quality; October 2011. AHRQ Publication No. 11(12)-EHC003-EF. Available at www.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Conclusions (1 of 3)The number of ADHD cases identified has increased over time. Children from lower SES households are diagnosed with ADHD more often than children from higher SES households. However, children from higher SES households are more likely to receive treatment than those from lower SES households.High-strength evidence shows that parental behavior training is efficacious for preschoolers; however, parents often drop out.Reference:Charach A, Dashti B, Carson P, et al. Attention Deficit Hyperactivity Disorder: Effectiveness of Treatment in At-Risk Preschoolers; Long-Term Effectiveness in All Ages; and Variability in Prevalence, Diagnosis, and Treatment. Comparative Effectiveness Review No. 44 (Prepared by McMaster University Evidence-based Practice Center under Contract No. MME 2202 290-02-0020). Rockville, MD: Agency for Healthcare Research and Quality; October 2011. AHRQ Publication No. 11(12)-EHC003-EF. Available at www.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Conclusions (2 of 3)Evidence is insufficient to know if school-based interventions are effective for preschoolers, and there are very few data on the outcomes related to the use of ADHD medications in preschoolers other than MPH. For children 6 years of age or older, evidence is insufficient to know if nonpharmacologic treatments alone are beneficial in the long term. Evidence shows that ADHD medications are safe and effective for children 6 and older. For both preschoolers and children over the age of 6, long-term effectiveness and adverse effects are not well studied.Reference:Charach A, Dashti B, Carson P, et al. Attention Deficit Hyperactivity Disorder: Effectiveness of Treatment in At-Risk Preschoolers; Long-Term Effectiveness in All Ages; and Variability in Prevalence, Diagnosis, and Treatment. Comparative Effectiveness Review No. 44 (Prepared by McMaster University Evidence-based Practice Center under Contract No. MME 2202 290-02-0020). Rockville, MD: Agency for Healthcare Research and Quality; October 2011. AHRQ Publication No. 11(12)-EHC003-EF. Available at www.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Conclusions (3 of 3)Which interventions are best for which children and which behavior training programs are most suitable for parents is unknown. Limited evidence suggests that some subgroups of children may benefit from combined medication and behavioral interventions more than from medication alone. It is unclear how long treatment may be required, of what type, and for which subgroups.More adverse effects were reported in preschoolers than in primary school children. Moodiness and irritability often lead to discontinuation of treatment with MPH. Although children taking ADHD medications appear to have diminished growth rates, some studies found diminished growth is not permanent and the children eventually catch up on their growth.Reference:Charach A, Dashti B, Carson P, et al. Attention Deficit Hyperactivity Disorder: Effectiveness of Treatment in At-Risk Preschoolers; Long-Term Effectiveness in All Ages; and Variability in Prevalence, Diagnosis, and Treatment. Comparative Effectiveness Review No. 44 (Prepared by McMaster University Evidence-based Practice Center under Contract No. MME 2202 290-02-0020). Rockville, MD: Agency for Healthcare Research and Quality; October 2011. AHRQ Publication No. 11(12)-EHC003-EF. Available at www.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Gaps in Knowledge (1 of 2)Data regarding the long-term effectiveness or possible adverse effects for all ADHD treatments are scarce. The few long-term studies that are available are mostly on medications. Much of the current evidence is based primarily on boys. Interventions in subgroups not commonly investigated to this point in time are needed, specifically individuals with a primarily inattentive subtype of ADHD, girls, teenagers, and adults. Other groups of interest are ethnic minorities and families of low socioeconomic status.Reference:Charach A, Dashti B, Carson P, et al. Attention Deficit Hyperactivity Disorder: Effectiveness of Treatment in At-Risk Preschoolers; Long-Term Effectiveness in All Ages; and Variability in Prevalence, Diagnosis, and Treatment. Comparative Effectiveness Review No. 44 (Prepared by McMaster University Evidence-based Practice Center under Contract No. MME 2202 290-02-0020). Rockville, MD: Agency for Healthcare Research and Quality; October 2011. AHRQ Publication No. 11(12)-EHC003-EF. Available at www.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Gaps in Knowledge (2 of 2)Little specific information is available regarding outcomes for children with comorbid learning disabilities, language impairments, reading, mathematics disorders, or other comorbidities.Investigations of parental preferences regarding behavior training are needed to determine if parental completion rates for training can be improved.Very few studies examined psychostimulant use for preschoolers. More research on the effectiveness and adverse effects of medication is needed in the younger age groups who are now receiving treatment in increasing numbers.Very few randomized clinical trials offer information about parental training interventions designed specifically for preschoolers with ADHD. Some studies adjusted the parental behavior training to address ADHD specifically, but other interventions also showed improvement in measured ADHD symptoms without adjustment. Evaluation is required regarding the need for specific adjustments to assist children with ADHD.Reference:Charach A, Dashti B, Carson P, et al. Attention Deficit Hyperactivity Disorder: Effectiveness of Treatment in At-Risk Preschoolers; Long-Term Effectiveness in All Ages; and Variability in Prevalence, Diagnosis, and Treatment. Comparative Effectiveness Review No. 44 (Prepared by McMaster University Evidence-based Practice Center under Contract No. MME 2202 290-02-0020). Rockville, MD: Agency for Healthcare Research and Quality; October 2011. AHRQ Publication No. 11(12)-EHC003-EF. Available at www.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • What To Discuss With Your Patients and Their CaregiversThings you should discuss with your patients and their caregivers regarding ADHD in children include:How ADHD affects children and their families. Potential benefits associated with nonpharmacologic interventions such as parental behavior therapy programs. Potential benefits and adverse effects associated with psychostimulants and nonstimulants. In choosing medications, it is useful to discuss dose timing and monitoring to make choices most compatible with treatment goals and patient schedules and lifestyle. Patient preferences regarding diagnosis and treatment options, including pharmacologic and nonpharmacologic interventions. How they can access information from the National Resource Center on ADHD about diagnosis and treatment, educational programs, public benefits, and other issues. The Center is supported with funding from the Federal Government through the Centers for Disease Control and Prevention (CDC). ADHD information can be accessed online at www.help4adhd.org or by phone at 800-233-4050.Reference:Charach A, Dashti B, Carson P, et al. Attention Deficit Hyperactivity Disorder: Effectiveness of Treatment in At-Risk Preschoolers; Long-Term Effectiveness in All Ages; and Variability in Prevalence, Diagnosis, and Treatment. Comparative Effectiveness Review No. 44 (Prepared by McMaster University Evidence-based Practice Center under Contract No. MME 2202 290-02-0020). Rockville, MD: Agency for Healthcare Research and Quality; October 2011. AHRQ Publication No. 11(12)-EHC003-EF. Available at www.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.

 Treatment Options for Attention Deficit Hyperactivity Disorder Treatment Options for Attention Deficit Hyperactivity Disorder Presentation Transcript

  • Treatment Options for Attention Deficit Hyperactivity Disorder Prepared for: Agency for Healthcare Research and Quality (AHRQ) www.ahrq.gov
  • Outline of Material Introduction to attention deficit hyperactivity disorder (ADHD) and treatment options Systematic review methods The clinical questions addressed by the CER Results of studies and evidence-based conclusions on the effectiveness of ADHD treatments for preschoolers and individuals 6 years of age and older Unrated findings on adverse effects of ADHD treatments Unrated conclusions on variability in the prevalence, clinical identification, and treatment of ADHD associated with potential moderating factors Gaps in knowledge and future research needs What to discuss with patients and their caregiversCharach A, Dashti B, Carson P, et al. AHRQ Comparative Effectiveness Review No. 44. October 2011. Available atwww.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Background: Characteristics of ADHD (1 of 3)ADHD affects children of all ages.Approximately 5% of children worldwide show impaired levels of inattention and hyperactivity.There are three subtypes of ADHD:  Predominantly inattentive  Predominantly hyperactive-impulsive  Combined inattentive and hyperactiveBoys are classified with ADHD about twice as frequently as girls.Young children are classified with ADHD about twice as frequently as adolescents.Charach A, Dashti B, Carson P, et al. AHRQ Comparative Effectiveness Review No. 44. October 2011. Available atwww.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Background: Characteristics of ADHD (2 of 3)Clinically significant ADHD is often associated with concurrent defiant and disruptive behaviors, temper tantrums, anxiety, low self-esteem, and learning disabilities.ADHD is most commonly identified and treated in elementary school (ages 7 to 9) but can begin before children enter school.There is an increasing interest in identifying children who show signs of ADHD at a very young age so they can be treated as early as possible to diminish social and academic repercussions.Charach A, Dashti B, Carson P, et al. AHRQ Comparative Effectiveness Review No. 44. October 2011. Available atwww.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Background: Characteristics of ADHD (3 of 3)Overall, levels of symptoms of hyperactivity and impulsivity decrease with age.However, many children with ADHD continue to show impairment relative to same-age peers throughout adolescence and into adulthood.Charach A, Dashti B, Carson P, et al. AHRQ Comparative Effectiveness Review No. 44. October 2011. Available atwww.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Background: ADHD InterventionsInterventions for ADHD include a range of pharmacologic and nonpharmacologic options.Psychostimulants and nonstimulant medications are often prescribed.Children with ADHD and their families may also receive nonspecific psychosocial support, counseling, and advice through standardized programs for parents and children.Children with ADHD may receive academic tutoring and coaching, both within and outside of school settings.Complementary and alternative medicine options, including dietary supplements, are also available, but are not covered in this review.Charach A, Dashti B, Carson P, et al. AHRQ Comparative Effectiveness Review No. 44. October 2011. Available atwww.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Background: ADHD Medications (1 of 2) Medication Brand Name Stimulants Mixed Amphetamine Salts Adderall®, Adderall XR® Dextroamphetamine Dexedrine® Lisdexamfetamine* Vyvanse®* Concerta® Daytrana® Focalin®*, Focalin XR®* Methylphenidate (MPH) Metadate ER®, Metadate CD® Methylin®, Methylin ER® Ritalin®, Ritalin LA®, Ritalin SR® •These medications were not included in this report CD = continuous dose; ER = extended release; LA = long acting; SR = sustained release; XR = extended releaseCharach A, Dashti B, Carson P, et al. AHRQ Comparative Effectiveness Review No. 44. October 2011. Available atwww.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Background: ADHD Medications (2 of 2) Medication Brand Name Nonstimulants Atomoxetine Strattera® Clonidine hydrochloride* Kapvay®* Guanfacine ER Intuniv® *These medications were not included in this report ER = extended releaseCharach A, Dashti B, Carson P, et al. AHRQ Comparative Effectiveness Review No. 44. October 2011. Available atwww.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Background: Behavior Training InterventionsBehavior training programs teach parents effective strategies to strengthen their bond with their child and improve their child’s behavior.There are many standardized programs for behavior training interventions for parents. Four widely disseminated examples include:  Positive Parenting Program (Triple P)  The Incredible Years Parenting Program (IYPP)  Parent-Child Interaction Therapy (PCIT)  The New Forest Parenting Program (NFPP)Charach A, Dashti B, Carson P, et al. AHRQ Comparative Effectiveness Review No. 44. October 2011. Available atwww.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • AHRQ CER Development Topics are nominated through a public process, which includes submissions from health care professionals, professional organizations, the private sector, policymakers, members of the public, and others. A systematic review of all relevant clinical studies is conducted by independent researchers, funded by AHRQ, to synthesize the evidence in a report summarizing what is known and not known about the selected clinical issue. The research questions and the results of the report are subject to expert input, peer review, and public comment. The results of these reviews are summarized into clinician research summaries and consumer research summaries for use in decisionmaking and in discussions with patients. The summaries and the full report, with references for included and excluded studies are available at www.effectivehealthcare.ahrq.gov.Charach A, Dashti B, Carson P, et al. AHRQ Comparative Effectiveness Review No. 44. October 2011. Available atwww.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Clinical Questions Addressed by the CERKey Question (KQ) 1: Among children younger than 6 years of age with ADHD or disruptive behavior disorder (DBD), what are the effectiveness and adverse event outcomes following treatment?KQ 2: Among people 6 years of age or older with ADHD, what are the effectiveness and adverse event outcomes following 12 months or more of any combination of followup or treatment, including, but not limited to, 12 months or more of continuous treatment?KQ 3: How do a) underlying prevalence of ADHD and b) rates of diagnosis (clinical identification) and treatment for ADHD vary by geography, time period, provider type, and socioeconomic characteristics?Charach A, Dashti B, Carson P, et al. AHRQ Comparative Effectiveness Review No. 44. October 2011. Available atwww.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Rating the Strength of Evidence From the CERThe strength of evidence was classified into four broad categories: High ●●● Further research is very unlikely to change the confidence in the estimate of effect. Moderate ●● Further research may change the confidence in the estimate of effect and may change the estimate. Low ● Further research is likely to change the confidence in the estimate of effect and is likely to change the estimate. Insufficient Evidence either is unavailable or does not permit estimation of an effect. Charach A, Dashti B, Carson P, et al. AHRQ Comparative Effectiveness Review No. 44. October 2011. Available at www.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Effectiveness of ADHD or DBD Interventions inChildren Under 6 Years of Age (1 of 2)Parental behavior training is an efficacious treatment option for preschoolers with disruptive behavior disorders or ADHD symptoms.  Benefits for children with DBD are maintained at least 6 months and up to 2 years in some studies.  Parents who attend more parental behavior training sessions see more improvement in their child’s behavior.  Strength of evidence: HighMethylphenidate (MPH) is efficacious and generally safe for treating ADHD symptoms, but there has been limited long-term followup in preschoolers beyond 12 months.  Strength of evidence: LowCharach A, Dashti B, Carson P, et al. AHRQ Comparative Effectiveness Review No. 44. October 2011. Available atwww.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Effectiveness of ADHD or DBD Interventions inChildren Under 6 Years of Age (2 of 2)Evidence is insufficient to know if there is an additional benefit to combining different treatments.  Strength of evidence: InsufficientIt should be noted that where there is socioeconomic burden, a school-based intervention appears to be the primary beneficial intervention. Benefits, however, diminished over 2 years. This appears to be related to lack of parental engagement and attendance at sessions.  Strength of evidence: InsufficientCharach A, Dashti B, Carson P, et al. AHRQ Comparative Effectiveness Review No. 44. October 2011. Available atwww.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Long-term (>1 Year) Effectiveness of ADHD Interventions inIndividuals 6 Years of Age or Older: Pharmacologic Psychostimulants provide control of ADHD symptoms and are generally well tolerated for months to years at a time.  The best evidence is for MPH in the setting of careful medication monitoring for up to 14 months.  Strength of evidence: Low Atomoxetine (ATX) appears to be safe and effective for treating ADHD symptoms over 12 months.  Strength of evidence: Low Extended-release guanfacine may reduce ADHD symptoms, but evidence is insufficient to permit an evidence-based conclusion about its long-term effectiveness.  Strength of evidence: InsufficientCharach A, Dashti B, Carson P, et al. AHRQ Comparative Effectiveness Review No. 44. October 2011. Available atwww.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Long-term (>1 Year) Effectiveness of ADHD Interventions inIndividuals 6 Years of Age or Older: Nonpharmacologic Evidence is insufficient to know if behavioral or psychosocial treatment alone is an effective long-term treatment option for children 6 years or older with ADHD.  Strength of evidence: Insufficient There are not enough studies to know if parental behavior training or school-based interventions are effective long-term treatment options for children 6 years or older with ADHD.  However, one good-quality study and its extension showed that school-based programs to enhance academic skills are effective in improving achievement scores in multiple domains.  Strength of evidence: InsufficientCharach A, Dashti B, Carson P, et al. AHRQ Comparative Effectiveness Review No. 44. October 2011. Available atwww.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Long-term (>1 Year) Effectiveness of ADHD Interventions inIndividuals 6 Years of Age or Older: Combined TreatmentsBoth psychostimulant medication alone and a combination of medication and behavioral treatment are effective in treating ADHD plus oppositional defiant disorder symptoms in children.  Results are most applicable to elementary school-age boys of normal intelligence with the combined subtype of ADHD.  Strength of evidence: LowCharach A, Dashti B, Carson P, et al. AHRQ Comparative Effectiveness Review No. 44. October 2011. Available atwww.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Adverse Effects (1 of 3)Although not critically evaluated within the report, generalresearch on adverse effects associated with ADHDtreatments suggests the following:Psychostimulants and ATX may cause insomnia, appetite loss, tiredness, social withdrawal, and abdominal pain.Psychostimulants and ATX may also cause a modest increase in average blood pressure and average heart rate in some children and adolescents.Children or adolescents taking ATX may be more likely to think about suicide than those who do not take it.Charach A, Dashti B, Carson P, et al. AHRQ Comparative Effectiveness Review No. 44. October 2011. Available atwww.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Adverse Effects (2 of 3)More adverse effects were reported in preschoolers than in primary school children.Moodiness and irritability often led to discontinuation of treatment with MPH.ADHD medications appear to have a small but distinct dose-related impact on growth rates in children.  Some studies found that although children taking ADHD medications appear to have diminished growth rates, they may eventually catch up on their growth over time.Safety investigations from observational studies and administrative databases did not provide conclusive evidence for cardiovascular or cerebrovascular adverse effects.Charach A, Dashti B, Carson P, et al. AHRQ Comparative Effectiveness Review No. 44. October 2011. Available atwww.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Adverse Effects (3 of 3)GXR was not well tolerated in studies, with less than 20 percent of participants completing the studies at 12 months. Adverse effects include somnolence or sedation, fatigue, headache, and possible weight gain. Abnormal or worsening electrocardiographic changes judged clinically significant in 1 percent of patients suggest that monitoring of cardiac status is indicated.Charach A, Dashti B, Carson P, et al. AHRQ Comparative Effectiveness Review No. 44. October 2011. Available atwww.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Variability in Prevalence, Clinical Identification,and Treatment of ADHD in Children (1 of 5) Factor Conclusions Location • Cultural differences influence how ADHD is understood and treated in different countries. • After taking into account differences in research methodologies between countries, the underlying prevalence does not appear to vary much among countries. • Rates of diagnosis vary considerably due to cultural context, access to local health care services, and providers available in the area. • There are significant regional variations in clinical identification across the United States. • Rates of treatment vary considerably due to location and access to health care providersinternationally, regionally, and even within the same community.Charach A, Dashti B, Carson P, et al. AHRQ Comparative Effectiveness Review No. 44. October 2011. Available atwww.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Variability in Prevalence, Clinical Identification,and Treatment of ADHD in Children (2 of 5) Factor Conclusions Service • Providers vary in their level of expertise in diagnosing Provider ADHD, as well as in familiarity with screening instruments and classification systems. Informant • Rates of diagnosis vary considerably due to cultural context. Some ethnicities are more likely to seek help or accept the diagnosis than others. • The sociocultural experience of the parent or teacher informant may influence interpretation and reporting of behaviors, willingness and persistence in seeking professional help, and/or acceptance of treatment modalities.Charach A, Dashti B, Carson P, et al. AHRQ Comparative Effectiveness Review No. 44. October 2011. Available atwww.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Variability in Prevalence, Clinical Identification,and Treatment of ADHD in Children (3 of 5) Factor Conclusions Time Period • Since being identified as a clinical entity in 1902, the prevalence of identified ADHD cases has increased. • This is partially due to increased knowledge about ADHD. It is also partially due to changes in the definition of who can identify a child as having ADHD (parents and teachers are becoming informants), changes in screening tests, and changes in diagnostic categories and classification systems over time. • The medical use of MPH or drug treatment of ADHD has increased steadily since the early 1980s. • As an indicator of trends in treatment, the International Narcotics Control Board reported that medical use of MPH in the United States increased 77 percent from 2004 to 2008.Charach A, Dashti B, Carson P, et al. AHRQ Comparative Effectiveness Review No. 44. October 2011. Available atwww.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Variability in Prevalence, Clinical Identification,and Treatment of ADHD in Children (4 of 5) Factor Conclusions Socioeconomic • Some studies found that children of lower SES have a Status higher prevalence of ADHD. • Children of lower SES are identified as having ADHD more often than children of higher SES; however, the latter are more likely to be receiving treatment. • Lower SES and minority ethnicity are associated with shorter duration of medication use. • Insurance status may influence access to specialist providers in the United States. Sex • Most studies found the prevalence of ADHD is greater in boys than in girls. • There are few comparative data examining rates of treatment by sex in children diagnosed with ADHD. SES = socioeconomic statusCharach A, Dashti B, Carson P, et al. AHRQ Comparative Effectiveness Review No. 44. October 2011. Available atwww.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Variability in Prevalence, Clinical Identification,and Treatment of ADHD in Children (5 of 5) Factor Conclusions Age • Children ages 5 to 10 years appear to have the highest prevalence of ADHD. • Elementary school children are identified as having ADHD more frequently than older children. • Medication treatment prevalence is higher for elementary school children than for adolescents or adults.Charach A, Dashti B, Carson P, et al. AHRQ Comparative Effectiveness Review No. 44. October 2011. Available atwww.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Conclusions (1 of 3)The number of ADHD cases identified has increased over time.Children from lower SES households are diagnosed with ADHD more often than children from higher SES households.  However, children from higher SES households are more likely to receive treatment than those from lower SES households.High-strength evidence shows that parental behavior training is efficacious for preschoolers; however, parents often drop out. SES = socioeconomic statusCharach A, Dashti B, Carson P, et al. AHRQ Comparative Effectiveness Review No. 44. October 2011. Available atwww.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Conclusions (2 of 3)Evidence is insufficient to know if school-based interventions are effective for preschoolers, and there are very few data on ADHD medications in preschoolers other than MPH.For children 6 years of age or older, evidence is insufficient to know if nonpharmacologic treatments alone are beneficial in the long term.Evidence shows that ADHD medications are safe and effective for children 6 and older.For both preschoolers and children over the age of 6, long-term effectiveness and adverse effects are not well studied.Charach A, Dashti B, Carson P, et al. AHRQ Comparative Effectiveness Review No. 44. October 2011. Available atwww.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Conclusions (3 of 3) Which interventions are best for which children and which behavior training programs are most suitable for parents is unknown. Limited evidence suggests that some subgroups of children may benefit from combined medication and behavioral interventions more than from medication alone.  It is unclear how long treatment may be required, of what type, and for which subgroups. More adverse effects were reported in preschoolers than in elementary school children. Moodiness and irritability often lead to discontinuation of treatment with MPH. Although children taking ADHD medications appear to have diminished growth rates, some studies found diminished growth is not permanent and the children may eventually catch up on their growth.Charach A, Dashti B, Carson P, et al. AHRQ Comparative Effectiveness Review No. 44. October 2011. Available atwww.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Gaps in Knowledge (1 of 2)Data regarding the long-term effectiveness or possible adverse effects for all ADHD treatments are scarce.  The few long-term studies that are available are mostly on medications.Studies are needed to compare effectiveness of diagnosis and treatment for girls, as the current evidence is based primarily on boys.Other populations that need further research include ethnic minorities and families of low socioeconomic status.Charach A, Dashti B, Carson P, et al. AHRQ Comparative Effectiveness Review No. 44. October 2011. Available atwww.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • Gaps in Knowledge (2 of 2)Little specific information is available regarding outcomes for children with comorbid learning disabilities, language impairments, and reading or mathematics disorders.Investigations of parental preferences regarding behavior training are needed to determine if parental completion rates for training can be improved.Very few studies examined psychostimulant use for preschoolers.Very few randomized clinical trials offer information about parental training interventions designed specifically for preschoolers with ADHD.Charach A, Dashti B, Carson P, et al. AHRQ Comparative Effectiveness Review No. 44. October 2011. Available atwww.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.
  • What To Discuss With Your Patients and TheirCaregivers How ADHD affects children or adolescents and their families. Potential benefits associated with nonpharmacologic interventions such as parental behavior therapy programs. Potential benefits and adverse effects associated with psychostimulants and nonstimulants. Patient preferences regarding diagnosis and treatment options, including pharmacologic and nonpharmacologic interventions. How they can access information from the National Resource Center on ADHD about diagnosis and treatment, educational programs, public benefits, and other issues.Charach A, Dashti B, Carson P, et al. AHRQ Comparative Effectiveness Review No. 44. October 2011. Available atwww.effectivehealthcare.ahrq.gov/adhdtreatment.cfm.