January 1, 1999

A National Institutes of Health (NIH) consensus panel recently concluded that the diagnosis, treatment, and follow-up of children with attention deficit/hyperactivity disorder, the most commonly diagnosed psychiatric disorder in children, remain inconsistent at best.

"These children are subjected to a fragmented treatment system that reaches beyond health care into a wide range of social and educational support services. The impact on individuals, families, schools, and society is profound and demands our immediate attention," said panel chair David Kupfer, M.D., in a press statement about the panel's report.

Kupfer, the Thomas Detre Professor and chair of the department of psychiatry at the University of Pittsburgh, met with 12 other experts at NIH in Bethesda, Md., for two days in November to address the controversy surrounding ADHD, especially the use of psychostimulants in children with the disorder.

Panelists and speakers expressed opposing views about the use of such stimulants. "There was a broad range of opinions-some were against psychostimulants, while others felt they had an important place in the care and management of children with ADHD along with careful evaluation and monitoring, and communication with patients, parents, and teachers," panelist Samuel Guze, M.D., told Psychiatric News.

Guze chairs APA's Council on Research and is the Spencer T. Olin Professor of Psychiatry at Washington University School of Medicine in St. Louis.

The general consensus of the panel was that the optimal treatment strategy should include medication and behavioral therapy, said Guze.

Short-term studies have established that stimulants, especially methylphenidate, improve the core symptoms of ADHD (inattention, hyperactivity, impulsivity, and aggression), according to the report. Similarly, clinical behavioral therapy, parent training, and contingency management have produced beneficial effects.

Long-term studies are needed, however, to examine the effect of medication and psychosocial treatments on academic and occupational achievement, as well as other areas of social functioning, recommended the panel.

Studies are also needed to achieve a better understanding of the cause or causes of ADHD. "Currently, we have no strategies for the prevention of ADHD," stated the report.

Because of the wide variation in diagnostic practices among practitioners in different fields, the panel recommended developing standardized diagnostic criteria that are age and gender specific. Research is also needed to better define ADHD and should include cognitive development and cognitive processing and brain imaging studies before initiating medication and then following the individual through young adulthood and middle-age. Additional studies should examine comorbid conditions in children and adults.

The panel also recommended developing practice guidelines that could be used by psychiatrists, primary care and developmental pediatricians, family practitioners, child neurologists, and psychologists. The American Academy of Child and Adolescent Psychiatry has the only published practice guidelines on ADHD.

The report also noted that pediatricians, family practitioners, and psychiatrists tend to rely on parent rather than teacher input in the diagnosis and treatment of ADHD. "There is often poor communication between diagnosticians and those who implement and monitor treatment in schools. In addition, follow-up may be fragmented and inadequate."

The panel called for developing integrated programs for diagnosis and treatment including training to help teachers recognize and understand behavioral problems frequently associated with ADHD, noted the statement.

Guze added that the panel agreed with the recommendations presented by Deborah Zarin, M.D., APA deputy medical director and director of the Office of Quality Improvement.

Zarin, a child psychiatrist and researcher, emphasized that care for children with ADHD must include a comprehensive evaluation to detect the disorder and possible comorbid conditions.

Policy and clinical recommendations should be broad enough to address a subset of children with ADHD who have a complex array of psychosocial, psychiatric, and general medical problems.

"In a national, practice-based study in 1995 by the APA Practice Research Network," Zarin testified, "69 percent of children with ADHD seen by psychiatrists had at least one comorbid diagnosis. More specifically, 20 percent had a diagnosed mood disorder, 36 percent were in a special education program, and 12 percent had a major impairment in several functional areas."

Resources must also be allocated to provide the level of evaluation and monitoring necessary for optimal treatment.

"It has been amply demonstrated that optimal treatment of even children with uncomplicated ADHD involves frequent visits with a clinician who gathers and integrates data from the parents, the school, and others to inform the treatment plan," testified Zarin. "However, the resources in terms of clinician time and finances necessary to provide such comprehensive treatment are rarely available."

The text of the NIH consensus panel report is posted at odp.od.nih.gov/consensus. The ADHD practice parameters are posted at www.aacap.org.