Report 10 of the Council on Science and Public Health (A-07)

Attention Deficit Hyperactivity Disorder

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Summary

Objective.  To update the 1997 report of this Council on the diagnosis and treatment of attention deficit hyperactivity disorder (ADHD).

Methods.  To supplement the literature search from the 1997 Council report, English-language reports on studies using human subjects were selected from a MEDLINE search of the literature from 1997 to February 2006 using the term attention deficit disorder, or attention deficit disorder with hyperactivity* in combination with diagnosis, epidemiology, drug therapy, genetics, or psychology. In addition, the Cochrane Central Controlled Trials Register was searched using the terms ADHD or attention deficit disorder and a manual search of the index for the Journal of Attention Disorders was conducted from 1996 to 2007. Web sites of the American Academy of Pediatrics, National Institute of Mental Health, Food and Drug Administration (FDA), American Academy of Child and Adolescent Psychiatry, and the American Psychiatric Association also were searched for documents relevant to ADHD.  A total of 596 articles were retrieved for analysis.  When high-quality systematic reviews and meta-analyses were identified, they formed the basis for evaluative statements about treatment safety and efficacy.  Additional articles were identified by manual review of the references cited in these publications.

Results.  Research increasingly points to ADHD as a developmental disorder of probable neurogenetic origin in which environmental factors also play a role, albeit more limited, in disease expression.  ADHD remains the most common reason for referral of children for mental health services, but is increasingly recognized as a lifespan disorder.  Diagnosis of ADHD in children is based on meeting the criteria of the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV-TR, but developmentally appropriate criteria for adults are lacking.  Stimulants are the most effective treatment for reducing core ADHD symptoms.  The addition of psychosocial interventions may be effective in reducing related behavioral and emotional difficulties, with less substantial effects on core ADHD symptoms, compared with stimulant medication.  Recent concerns about the cardiovascular risks and potential psychiatric side effects of medications used to treat ADHD have resulted in modifications to the product labeling for medications approved to treat ADHD, and a requirement for the development of medication guides.

Conclusion.  Diagnosis of ADHD in children is based on meeting the criteria of the DSM-IV-TR.  Because the criteria are subjective and may be interpreted differently by different observers, their use and applicability to general practice settings may vary somewhat.  Clinical samples have not been diverse, with an overrepresentation of Caucasian males. Further information is needed to inform treatment of minority populations and those from lower socioeconomic strata. With the recognition that a substantial percentage of children diagnosed with ADHD have symptoms that persist into adulthood, developmentally valid criteria for adults also need to be refined.  The treatment of ADHD requires expertise in many different treatment modalities. Stimulant medication offers the most effective treatment for reducing core symptoms.  Although the FDA has recently taken actions to strengthen warnings on the product labeling for medications approved to treat ADHD, some disagreement continues about the risks of these medications.

RECOMMENDATION

The following statement, recommended by the Council on Science and Public Health, was adopted by the AMA House of Delegates as policy at the 2007 AMA Annual Meeting:

AMA Policy H-60.950, Diagnosis and Treatment of Attention Deficit/Hyperactivity Disorder in School-Age Children,  is amended  to read as follows:

The AMA: (1) encourages physicians to utilize standardized diagnostic criteria in making the diagnosis of ADHD, such as the American Psychiatric Association's DSM-IV, as part of a comprehensive evaluation of children and adolescents presenting with attentional or hyperactivity complaints; (2) urges that attention be directed toward establishing developmentally appropriate criteria for the diagnosis and treatment of ADHD in adults; (3) encourages the creation and dissemination of practice guidelines for ADHD by appropriate specialty societies and their use by practicing physicians and assist in making physicians aware of their availability; (4) encourages efforts by medical schools, residency programs, medical societies, and continuing medical education programs to increase physician knowledge about ADHD and its treatment; (5) encourages the use of individualized therapeutic approaches for patients diagnosed with ADHD, which may include pharmacotherapy, psycho-education, behavioral therapy, school-based and other environmental interventions, and psychotherapy as indicated by clinical circumstances and family preferences; (6) encourages physicians and medical groups to work with schools to improve teachers' abilities to recognize ADHD and appropriately recommend that parents seek medical evaluation of potentially affected children; and (7) encourages further research on the relative risks and benefits of medication used to treat ADHD, including evaluation of  the impact of labeling changes on access to treatment and physician prescribing. (Policy)

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