National Institute of Mental Health
Children with attention deficit hyperactivity disorder (ADHD) often receive an inconsistent level of care from a fragmented system that consumes a large share of health care dollars, according to a consensus panel convened by the National Institutes of Health (NIH).
"There is no consistency in treatment, diagnosis or followup for children with ADHD. It is a major public health problem," said panel chair Dr. David J. Kupfer, Thomas Detre Professor and Chair, Department of Psychiatry, University of Pittsburgh.
"These children are subjected to a fragmented treatment system that reaches beyond health care into a wide range of social and educational support services. Its impact on individuals, families, schools, and society is profound, and it demands our immediate attention," Dr. Kupfer said.
The problem is compounded by the fact that an accurate diagnosis for ADHD remains elusive and controversial yet continues to be a commonly diagnosed behavioral disorder of childhood. One of the most important, immediate research needs is to develop standardized diagnostic criteria based on age and gender, the panel said.
While the panelists concluded that the absence of a simple, consistent diagnostic test for ADHD continues to pose validity problems for the disorder, they agreed that the 3 to 5 percent of school age children grappling with ADHD experience an inability to sit still and pay attention in class, peer rejection, and disruptive behaviors, which can lead to academic and social difficulties. Other long-term consequences include higher rates of accidents as well as alcohol and drug abuse and criminal behaviors when ADHD is accompanied by conduct problems.
Diagnosis and treatment inconsistencies often begin with the practitioner. Studies show that most children with ADHD are diagnosed by family practitioners; pediatricians diagnose fewer patients but typically spend a longer amount of time with each patient. Family practitioners also prescribe medications more frequently than pediatricians or psychiatrists; comorbid symptoms of ADHD also are less frequently diagnosed by primary care physicians, according to the panel.
Studies show that there is inadequate communication between the physician diagnosing the child and the educators who must play a key role in implementing and monitoring the prescribed treatments. The panel emphasized the importance of cooperation between practitioners and educators in diagnosing and treating children with ADHD. The group called for more training to help teachers recognize and understand behavioral problems frequently associated with ADHD and to develop the skills to interact with the children in the classroom.
Although experts disagree on the best approaches to treating ADHD-medication, behavioral therapy or a combination-many children face any number of barriers to treatment. Common barriers to mental health treatment include high out-of-pocket costs, little or no mental health insurance benefits, and few choices for lower income patients. Additional barriers to treatment access arise depending on gender, race, and geographical location, the panel said. In most school systems less than half of children with ADHD qualify for special education programs.
Treatment of ADHD with medication or certain types of behavioral therapy improves the behavior of children with ADHD, but there is no evidence that treatment improves academic achievement or long-term outcomes and research is needed in these areas.
Careful therapeutic use of stimulants is effective in treating the core symptoms of ADHD as long as a child is taking the medication. However, the panel identified the need to study the benefits and risks of long-term use of such medications. Although behavioral treatments produce positive short-term results, it remains unclear what combination of these strategies are most effective.
The panel issued their consensus statement at the conclusion of a 3-day NIH Consensus Development Conference on Diagnosis and Treatment of Attention Deficit Hyperactivity Disorder, during which they heard presentations by experts in the field and public testimony from interested organizations and individuals.
The full NIH Consensus Statement on Diagnosis and Treatment of Attention Deficit Hyperactivity Disorder is available by calling 1-888-NIH-CONSENSUS (1-888-644-2667) or by visiting the NIH Consensus Development Program Web site at http://consensus.nih.gov.
The NIH Consensus Development Program was established in 1977 as a form of "science court" to resolve in an unbiased manner controversial topics in medicine. To date, NIH has conducted 110 such conferences addressing a wide range of controversial medical issues important to health care providers, patients, and the general public. An average of six consensus conferences are held each year.
This conference was sponsored by the NIH Office of Medical Applications of Research, the National Institute of Mental Health, and the National Institute on Drug Abuse. The conference was cosponsored by the National Institute of Environmental Health Sciences, the National Institute of Child Health and Human Development, the U.S. Food and Drug Administration, and the Office of Special Education Programs, U.S. Department of Education.
NOTE TO RADIO EDITORS: An audio report of the conference results are available November 18-25, 1998 from the NIH Radio News Service by calling 1-800-MED-DIAL (1-800-633-3425) or by visiting http://www.radiospace.com/nihhome.htm on the Web.