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2. What Is the Impact of ADHD on Individuals, Families, and Society?
Children with ADHD experience an inability to sit still and pay attention in class and the negative consequences of such behavior. They experience peer rejection and engage in a broad array of disruptive behaviors. Their academic and social difficulties have far-reaching and long-term consequences. These children have higher injury rates. As they grow older, children with untreated ADHD in combination with conduct disorders experience drug abuse, antisocial behavior, and injuries of all sorts. For many individuals, the impact of ADHD continues into adulthood.
Families who have children with ADHD, as with other behavioral disorders and chronic diseases, experience increased levels of parental frustration, marital discord, and divorce. In addition, the direct costs of medical care for children and youth with ADHD are substantial. These costs represent a serious burden for many families because they frequently are not covered by health insurance.
In the larger world, these individuals consume a disproportionate share of resources and attention from the health care system, criminal justice system, schools, and other social service agencies. Methodological problems preclude precise estimates of the cost of ADHD to society. However, these costs are large. For example, additional national public school expenditures on behalf of students with ADHD may have exceeded $3 billion in 1995. Moreover, ADHD, often in conjunction with coexisting conduct disorders, contributes to societal problems such as violent crime and teenage pregnancy.
Families of children impaired by the symptoms of ADHD are in a very difficult position. The painful decision-making process to determine appropriate treatment for these children is often made substantially worse by the media war between those who overstate the benefits of treatment and those who overstate the dangers of treatment.
3. What Are the Effective Treatments for ADHD?
A wide variety of treatments have been used for ADHD including, but not limited to, various psychotropic medications, psychosocial treatment, dietary management, herbal and homeopathic treatments, biofeedback, meditation, and perceptual stimulation/training. Of these treatment strategies, stimulant medications and psychosocial interventions have been the major foci of research. Studies on the efficacy of medication and psychosocial treatments for ADHD have focused primarily on a condition equivalent to DSM-IV combined type, meeting criteria for Inattention and Hyperactivity/Impulsivity. Until recently, most randomized clinical trials have been short term, up to approximately 3 months. Overall, these studies support the efficacy of stimulants and psychosocial treatments for ADHD and the superiority of stimulants relative to psychosocial treatments. However, there are no long-term studies testing stimulants or psychosocial treatments lasting several years. T here is no information on the long-term outcomes of medication-treated ADHD individuals in terms of educational and occupational achievements, involvement with the police, or other areas of social functioning.
Short-term trials of stimulants have supported the efficacy of methylphenidate (MPH) dextroamphetamine and pemoline in children with ADHD. Few, if any, differences have been found among these stimulants on average. However, MPH is the most studied and the most often used of the stimulants. These short-term trials have found beneficial effects on the defining symptoms of ADHD and associated aggressiveness as long as medication is taken. However, stimulant treatments may not “normalize” the entire range of behavior problems, and children under treatment may still manifest a higher level of some behavior problems than normal children. Of concern are the consistent findings that despite the improvement in core symptoms, there is little improvement in academic achievement or social skills.
Several short-term studies of antidepressants show that desipramine produces improvements over placebo in parent and teacher ratings of ADHD symptoms. Results from studies examining the efficacy of imipramine are inconsistent. Although a number of other psychotropic medications have been used to treat ADHD, the extant outcome data from these studies do not allow for conclusions regarding their efficacy.
Psychosocial treatment of ADHD has included a number of behavioral strategies such as contingency management (e.g., point/token reward systems, timeout, response cost) that typically is conducted in the classroom, parent training (where the parent is taught child management skills), clinical behavior therapy (parent, teacher, or both are taught to use contingency management procedures), and cognitive-behavioral treatment (e.g., self-monitoring, verbal self-instruction, problem-solving strategies, self-reinforcement). Cognitive-behavioral treatment has not been found to yield beneficial effects in children with ADHD. In contrast, clinical behavior therapy, parent training, and contingency management have produced beneficial effects. Intensive direct interventions in children with ADHD have produced improvements in key areas of functioning. However, no randomized control trials have been conducted on some of these intensive interventions alone or in combination with medication. Studies that compared stimulants with psychosocial treatment consistently reported greater efficacy of stimulants.
Emerging data suggest that medication using systematic titration and intensive monitoring methods over a period of approximately 1 year is superior to an intensive set of behavioral treatments on core ADHD symptoms (inattention, hyperactivity/impulsivity, aggression). Combined medication and behavioral treatment added little advantage overall, over medication alone, but combined treatment did result in more improved social skills, and parents and teachers judged this treatment more favorably. Both systematically applied medication (monitored regularly) and combined treatment were superior to routine community care, which often involved the use of stimulants. An important potential advantage for behavioral treatment is the possibility of improving functioning with reduced dose of stimulants. This possibility was not tested.
There is a long history of a number of other interventions for ADHD. These include dietary replacement, exclusion, or supplementation; various vitamin, mineral, or herbal regimens; biofeedback; perceptual stimulation; and a host of others. Although these interventions have generated considerable interest and there are some controlled and uncontrolled studies using various strategies, the state of the empirical evidence regarding these interventions is uneven, ranging from no data to well-controlled trials. Some of the dietary elimination strategies showed intriguing results suggesting the need for future research.
The current state of the empirical literature regarding the treatment of ADHD is such that at least five important questions cannot be answered. First, it cannot be determined if the combination of stimulants and psychosocial treatments can improve functioning with reduced dose of stimulants. Second, there are no data on the treatment of ADHD, Inattentive type, which might include a high percentage of girls. Third, there are no conclusive data on treatment in adolescents and adults with ADHD. Fourth, there is no information on the effects of long-term treatment (treatment lasting more than 1 year), which is indicated in this persistent disorder. Finally, given the evidence about the cognitive problems associated with ADHD, such as deficiencies in working memory and language processing deficits, and the demonstrated ineffectiveness of current treatments in enhancing academic achievement, there is a need for application and development of methods targeted to these weaknesses.
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