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Introduction

Attention-deficit hyperactivity disorder (ADHD) is the most commonly diagnosed behavioral disorder in

children, but it is often misunderstood as well as the subject of controversy. Confusion surrounding the

disorder has led to both under- and overtreatment of children. This report, based on my presentation at

APhA 2001, will review the current status of ADHD in the United States, diagnostic recommendations,

behavioral interventions, etiology, and pathophysiology.

Current Status of ADHD in the United States

In November 1998, the National Institutes of Health (NIH) gathered 44 experts in psychiatry, psychology,

epidemiology, biostatistics, and pediatrics from across the United States to review the literature on

ADHD and develop a consensus statement addressing key diagnostic and treatment issues. Results

confirmed that ADHD is a valid disorder with measurable and significant impairment in functioning

caused by inattention, impulsivity, and hyperactivity. The experts reported a 3% to 5% incidence in

school age children and acknowledged a need for improved assessment, treatment, and long-term

follow-up. The need for better integration of parents, teachers, and healthcare providers for optimal

assessment and treatment was emphasized. Stimulants were regarded as most effective in relieving

symptoms according to research, although there was no consensus regarding the threshold of

symptoms most appropriate for stimulant therapy.

ADHD incidence rates are 5 to 10 times greater in the United States compared with other countries.

There is significant regional variability in the diagnosis and treatment of ADHD across the United States

as well. For example, 8% to 10% of 30,000 children in second to fifth grade were diagnosed with ADHD

in 1 Virginia school system whereas the NIH reports a lower 3% to 5% incidence. Cultural differences inprescribing stimulants were reported in the same study; by fifth grade, 18% to 20% of white boys were

prescribed methylphenidate whereas rates were significantly lower in other ethnicities. There is

significant regional variability in the incidence of ADHD and drug therapy prescribing across the United

States but there has been a general increase in both over the past 10 years. One epidemiologic study

tracked 220,000 preschoolers from 1991-1995 (through Medicaid and HMO databases) and found that

1.2% were prescribed stimulants, 1.1% were prescribed antidepressants, and 0.32% were prescribed

clonidine for behavioral control. This represents a 3-fold increase in stimulant prescribing, a 2-fold

increase in antidepressant prescribing, and a 28-fold increase in clonidine prescribing between 1991 and

1995. A greater acceptance of pharmacologic treatments for behavioral disorders in children was sited

as 1 major reason for the increased prescribing in all age groups (2- to19-year-olds).

Under diagnosis and suboptimal treatment of children with ADHD is also a well-documented public

health issue. One study of treatment services for ADHD nationwide found that only 50% of children with

identified ADHD in real-world practice settings receive care that corresponds to guidelines of the

American Academy of Child and Adolescent Psychiatry. Barriers to appropriate service provision include

a lack of pediatric specialists, insurance obstacles, and long waiting lists to appropriate services.

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Between 1989 and 1996, related services, such as health counselling, for children with ADHD increased

10-fold, and diagnostic services increased 3-fold. Provision of psychotherapy, however, decreased from

40% of pediatric visits to only 25% in the same time frame. Follow-up care also decreased from more

than 90% of visits to only 75%. Other barriers to appropriate diagnosis and treatment include a fear of

stigma, fear of substance abuse, and unknown long-term effects of treatment.

Behavioral Interventions

The effectiveness of behavioral interventions was compared with methylphenidate therapy in the

Multimodal Treatment Study of Children With Attention-Deficit/Hyperactivity Disorder (MTA). This

landmark study included 579 children aged 7-10 years withDSM-IVADHD combined type. There were 3

active treatments (methylphenidate, behavioral treatment, and combination methylphenidate and

behavioral treatment), which were compared with community care or "naturalistic" treatment. This

controlled multicenter study was continued for 14 months. All active treatments received on-going

monitoring and coordination with parents, teachers, and clinicians. Community care included stimulanttherapy in two thirds of cases, but there was no systematic coordination of care. Parent training was an

integral part of behavioral interventions. Parent training included education on ADHD, counseling for

parents, training in contingency management techniques, and development of realistic expectations of

treatment.

Results of the MTA study showed that methylphenidate with or without behavioral therapy were

superior to behavioral therapy alone. All active treatments were superior to community care. Behavioral

interventions were regarded as valuable and effective treatments by parents and teachers. Researchers

concluded that clinician support, parent training, and teacher involvement were essential for optimal

treatment outcome in ADHD.

The most effective behavioral interventions include parent training and contingency management.

Contingency management involves rewards for good behavior, positive verbal feedback, and consistent

limit setting. Encouragement of focused exercises (such as assembling jigsaw puzzles) and attention to

the environment (avoiding excessive or under stimulation) can also be therapeutic.

Biofeedback, audio visual stimulation, and dietary changes have all been studied as behavioral

interventions for ADHD. Biofeedback involves monitoring brainwaves with electroencephalogram (EEG)

and providing positive reinforcement for "attentive" beta brain waves and negative consequences for

"distractible" theta brain waves. Special sets of glasses which provide lights and sounds to promote

attentive brain waves through "entrainment" has been proposed as an effective audio visual stimulation

treatment. These types of behavioral interventions including dietary manipulation and nutritional

supplements require further study before their place in therapy is determined.

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Confirming the Diagnosis Across the Life Span

A clinician with specialized expertise in child and adolescent neurodevelopment and behavior is best

able to generate a reliable diagnosis of ADHD. Because children are highly reactive to their environment,

it is crucial to enlist multiple informants (parents, teachers, siblings, child, caregivers) and rate

symptoms in multiple settings. A child or teen must exhibit at least 6 of 9 symptoms of inattention or

hyperactivity-impulsivity, or both, that are maladaptive and inconsistent with his or her developmental

level. The symptoms must present in multiple settings over a period of 6 months and have an onset by

age 7 before a diagnosis is confirmed. Several validated rating scales exist which are designed for

optimal diagnostic assessment. Adolescents with ADHD tend to exhibit less hyperactivity but continue

inattention and impulsivity. Approximately one third of individuals with ADHD continue to experience

significant symptoms into adulthood. Common comorbid conditions include oppositional-defiant

disorder, major depression, anxiety disorders, learning disability, and Tourette's disorder. The presence

of comorbid conditions can increase the likelihood of ADHD chronicity.