Current concepts and controversies in the diagnosis and treatment of attention deficit hyperactivity disorder

Abstract

Concerns about possible over-diagnosis and over-treatment of attention deficit hyperactivity disorder (ADHD) have been prominent in media reports, as have various competing claims about the safety and efficacy of the various treatments for ADHD. Drawing upon the results of the recent National Institutes of Health Consensus Conference, this paper reviews the evidence concerning these controversial areas. Although there do appear to be pockets of over-prescribing in selected communities, the best available evidence suggests that across the United States substantial underdiagnosis continues to occur, and only 50% of all children with ADHD are being treated with stimulant medications. Among those who are treated with stimulant medications, inadequate treatment is quite common. Substantial evidence suggests that for ADHD symptoms, stimulants are more effective than behavioral therapies in head-to-head comparisons. Combined medication and behavioral treatments do not offer any meaningful advantages over medication treatments alone for ADHD symptoms. For other areas of functioning, however (social skills, academic performance, etc.), combined treatments appear to offer some modest advantages over single treatment approaches. Although research findings show that ADHD can indeed be rigorously and reliably diagnosed under optimal conditions, and that carefully delivered treatments can yield substantial benefits, such best practices do not appear to be taking place in the real world. Thus, although the above controversies are facing some resolution in principal, in practice much remains to be done.

Quantitative electroencephalography and attention-deficit/hyperactivity disorder: Implications for clinical practice

“…Among the most commonly noted were lack of information about ADHD and the rationale for using medication, fear of a negative response to treatment, distrust of the assessment process, dissatisfaction with an assessment process limited to brief observation interview and review of behavior rating scales, lack of medication response within the fi rst month, development of side effects during the fi rst month, and insuffi cient clinical response [ 12•• , 13 , 14 ]. Although Jensen [ 15 ] accurately concluded that "research fi ndings show that ADHD can indeed be rigorously and reliably diagnosed under optimal conditions, and that carefully delivered treatments can yield substantial benefi ts," it also has been demonstrated that parents and caregivers of children with ADHD are reluctant to initiate and maintain treatment without a more comprehensive evaluation process. Based on a review of the factors impeding treatment initiation and retention, it appears that adherence to current practice guidelines is unlikely to substantially alter the percentage of patients with ADHD who are actually being treated.…”

Overcoming the barriers to effective treatment for attention-deficit/hyperactivity disorder: A neuro-educational approach

“…At the national level, Jensen et al (1999b) examined the total number of prescriptions written for stimulant medications in 1995 and concluded that only 25 -50% of children with AD/ HD received pharmacological treatment. Among those children, Jensen (2000) estimated that each child received only four to eight prescriptions per year. Finally, even in a study involving participants who were carefully diagnosed and highly motivated (MTA Cooperative Group, 1999), only two-thirds of the patients were treated with any medication during the 14-month study.…”

Treatment for ADHD: Is More Complex Treatment Cost‐Effective for More Complex Cases?

“…A key issue in the field involves the degree to which each of these treatments is more (or less) effective and cost-effective when combined with the other ( Jensen 2000).…”