Practice parameter for ADHD gets major update
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An underlying theme of the parameter is the recognition that the diagnosis and treatment of ADHD are ‘in the mainstream of American medicine and American psychiatry”, lead author said in an interview. ADHD is an international phenomenon now. It’s no different from screening for asthma or diabetes or treating those conditions. They have an equal degree of evidence of the biological causes and effective treatments. They want everyone to recognize that and go forward and help their patients.
In a process that began in late 2004, assembled 13 recommendations based on a review of nearly 5,000 references related to the diagnosis and treatment of ADHD that were generated between 1996 and 2006. The references included those from the 1997 version of the practice parameter, as well as those that appeared in the scientific medical literature, in book chapters, or in posters and presentations at scientific meetings.
Two chief developments drove the need to update the parameter. One is the proliferation of new treatments of ADHD that have emerged in the last 5-10 years. Another development is what he called “a growth of genetics and neuroimaging studies that are starting to point the way to the underlying causes and brain features of the disorder.
One recommendation in the 44-page document that differs from the 1997 version is based in part on results from the National Institute of Mental Health — sponsored multimodal treatment study of children with ADHD, which examined different treatment options for the disorder (Arch. Gen. Psychiatry 1999-56: 1073-86). That study concluded that careful medication management alone was superior to behavioral therapy as well as to routine community care that included medication.
While there’s debate about exactly how to interpret with other problems like learning disabilities, behavior disorders, or depression, then he or she needs a combined approach: the medication and some type of psychosocial intervention. They don’t recommend behavioral intervention alone except in milder cases or in cases where the diagnosis is in question. Other recommendations address medications used for ADHD.
They conclude that stimulant medications are usually the best first online treatment options. The current stimulants on the market “tend to be equally efficacious, and it’s largely a matter of family and physician preference as to which one you use.
The non-stimulant atomoxetine (Strattera) may be considered as a first-line treatment for some patients, such as those who experience co-occurring anxiety and tics.
The document notes that there may be a place in ADHD treatment for medications that are not approved by the Food and Drug Administration for that indication but that have demonstrated efficacy for ADHD in some studies. These agents include bupropion, tricyclic antidepressants, and x-agonists. But, these should only be tried if the ones in the approved group have failed.
The new practice parameter also addresses concerns about the potential for rare side effects, including aggression and mood liability, to occur with the use of stimulants. In controlled trials, there is no evidence that the stimulants produce these (side effects) in numbers greater than in the placebo groups. They acknowledge that they’ve been reported in post marketing studies and that physicians should be alert to them, but there’s not any undue concern. They shouldn’t be a reason that people would shy away from using the medication.
There have been some concerns about possible cardiovascular side effects based on reports of sudden death in people taking agents used in ADHD treatment.
However, we concluded in the document that the rates of sudden death of children on ADHD medications “do not appear to exceed the base rate of sudden death in the general population.” In the interview, we emphasized that we do not view cardiovascular side effects as a risk of the stimulants. The one group to be cautious with are those people that already have some pre-existing heart disease.
They predicted that neuroimaging is going to be a leading factor in ADHD research efforts in the future, but emphasized that, at this time, neuroimaging shouldn’t be used commercially to diagnose ADHD. The diagnosis is still made by the efforts of the physician talking to the family, talking to the child, and gathering data about behavior.
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