Diagnosis and Treatment of Attention Deficit Hyperactivity Disorder

National Institutes of Health
Consensus Development Conference Statement
November 16-18, 1998

cont.

6. What Are the Directions for Future Research?

Basic research is needed to better define ADHD. This research includes the following: (1) studies of cognitive development, cognitive processing, and attention/inattention in ADHD and (2) brain imaging studies before the initiation of medication and following the individual through young adulthood and middle age.

Further research should be conducted with respect to the dimensional aspects of this disorder, as well as the comorbid (coexisting) conditions present in both childhood and adult ADHD. Therefore, an important research need is the investigation of standardized age- and gender-specific diagnostic criteria.

The impact of ADHD should be determined. Studies in this regard include (1) the nature and severity of the impact on individuals, families, and society of adults with ADHD beyond the age of 20 and (2) determination of the financial costs related to diagnosis and care of children with ADHD.

Additional studies are needed to develop a more systematized treatment strategy. These include:

• Studies of the Inattentive type of ADHD, especially since it might include a higher proportion of girls than the subtypes with hyperactivity/impulsivity.
• Studies of long-term treatment (treatment lasting longer than 1 year), which are needed because of the persistence of the disorder.
• Prospective controlled studies, up to adulthood, of the risks and benefits associated with childhood treatment with psychostimulants.
• Studies to determine the effects of psychotropic therapy on cognitive function and school performance.
• Studies of the effects of instructional treatments on the academic achievement of children with ADHD.
• Studies to determine whether the combination of stimulants and psychosocial treatments can improve functioning with a reduced dose of stimulants.
• Studies to determine the risks and benefits associated with treating children younger than age 5 with stimulants.
• Studies of the effects of various stimulants in adolescents and adults.

Greater attention should be given to developing integrated programs for diagnosis and treatment. These include:

• Model projects to demonstrate methods of training teachers to recognize and provide appropriate special programs for children with ADHD.
• Incorporation of classroom strategies to effectively serve a greater variety of students and thereby reduce the need for ADHD referral and diagnosis.
• Determination of the extent to which individuals with ADHD are being served in postsecondary education and, if so, where they are being served, with what types of accommodations, and with what level of success.

Conclusions

Attention deficit hyperactivity disorder or ADHD is a commonly diagnosed behavioral disorder of childhood that represents a major public health problem. Children with ADHD usually have pronounced difficulties and impairments resulting from the disorder across multiple settings. They can also experience long-term adverse effects on academic performance, vocational success, and social-emotional development.

Despite progress in the assessment, diagnosis, and treatment of ADHD, this disorder and its treatment have remained controversial in many public and private sectors. The major controversy regarding ADHD continues to be the use of psychostimulants both for short-term and long-term treatment.

Although an independent 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 aspects of ADHD, as well as the comorbid (coexisting) conditions present in both childhood and adult ADHD. Therefore, 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. A considerable share of resources from the health care system and various social service agencies is currently devoted to individuals with ADHD. Often the services are delivered in a nonintegrated manner. Resource allocation based on better cost data leading to integrated care models needs to be developed for individuals with ADHD.

Effective treatments for ADHD have been evaluated primarily for the short term (approximately 3 months). These studies have included randomized clinical trials that have established the efficacy of stimulants and psychosocial treatments for alleviating the symptoms of ADHD and associated aggressiveness and have indicated that stimulants are more effective than psychosocial therapies in treating these symptoms. Lack of consistent improvement beyond the core symptoms leads to the need for treatment strategies that utilize combined approaches. At the present time, 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 physicians, suggesting no consensus among practitioners regarding which ADHD patients should be treated with psychostimulants. As measured by attention/activity indices, patients with varying levels and types of problems (and even possibly unaffected individuals) 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 followup. A more consistent set of diagnostic procedures and practice guidelines 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 educational services represent considerable long-term cost for society. The lack of information and education about accessibility and affordability of services must be remedied.

Finally, after years of clinical research and experience with ADHD, our knowledge about the cause or causes of ADHD remains speculative. Consequently, we have no strategies for the prevention of ADHD.

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