Case 2: Volume 1, Case #14: The scatter-brained mother whose daughter has ADHD, like mother, like daughter

Table B. KQ2: Long-term (>1 year) effectiveness of interventions for ADHD in people 6 years and older Conclusion Medication Treatment Level of Evidence Intervention SOE: Low Very few studies include untreated controls.

Studies were largely funded by industry.

SMD: -0.54 (95% Cl, -0.79 to -0.29) MPH:

Psychostimulants continue to provide control of ADHD symptoms and are generally well tolerated for months to years ATX: at a time. The evidence for MPH use in the context of careful SMD: -0.40 (95% medication monitoring shows good evidence for benefits for Cl, -0.61 to -0.18) symptoms for 14 months. ATX is effective for ADHD symptoms and well tolerated over 12 months.

SOE: Insufficient Only one study of GXR monotherapy is available. It reports reduced ADHD symptoms and global improvement, although less than a fifth of participants completed 12 months.

Monitoring of cardiac status may be indicated since approximately 1% of participants showed EGG changes judged clinically significant. Combined The results from 2 cohorts indicate both medication (MPH) and Psychostimulant SOE: Low combined medication and behavioral treatment are effective in Medication and SMD: -0.70 (95% treating ADHD plus ODD symptoms in children, primarily boys Behavioral ages 7-9 years of nomnal intelligence with combined type of Treatment Cl, -0.95 to -0.46) ADHD, especially during the first 2 years of treatment.

Several reports from one high-quality study suggest that combined medication and behavioral treatment improves outcomes more than medication alone for some subgroups of children with ADHD combined type and for some outcomes. Behavioral/ There is not enough evidence to draw conclusions for persons Psychosocial SOE:

Insufficient 6 years and older with a diagnosis ofADHD. Parent Behavior There is not enough evidence to draw conclusions for persons Training SOE:

Insufficient 6 years and older with a diagnosis of ADHD. Academic Interventions One good-quality study and its extension showed that classroom-based programs to enhance academic skills are effective in improving achievement scores in multiple domains, but following discontinuation, the benefits for sustained growth in academic skills are limited to the domain of reading fluency. All other domains show skill maintenance but not continued growth.

SOE:

Insufficient .. Note: ADHD- attention defictt hyperactlvtty dtsorder, ATX- atomoxetine, ECG- electrocardiOgram, GXR- guanfacme extended release; KQ =Key Question; MPH= methylphenidate; ODD= oppositional defiant disorder; SMD =standardized mean difference; SOE =strength ofevidence. ES-15 Pharmacological Interventions Multiple short-term studies document that psycho stimulant medications, either MPH, dextroamphetamine (DEX), or mixed amphetamine salts (MAS), effectively decrease the core symptoms of ADHD and associated impairment. 10 A review of the mechanisms of action of pharmacological interventions for ADHD is beyond the scope of this report. Some preparations last only a few hours, with symptoms returning as the medication wears off. Many families choose to use medication primarily on school days, and these medications have primarily been studied in school-aged children and youth aged 6 years and older. Psychostimulants, most connnonly MPH and DEX, are generally safe and well tolerated. Common side effects include poor appetite, insomnia, headaches, stomachaches, and increased blood pressure and heart rate.

Prolonged use may result in a decreased rate of growth, generally considered clinically insignificant.n 8 Concerns have been raised from postmarketing surveillance suggesting a rare incidence of sudden death, perhaps associated with pre-existing cardiac defects, however, the rate does not appear to exceed that of the base rate of sudden death in the population. 118 As noted earlier, approximately 2.5 million children in the United States, ages 4 to 17 years with a diagnosis of Attention Deficit Disorder (ADD) or ADHD, cunently take medication. 4 Several extended release preparations of psychostimulants have been developed in recent years aimed at improved adherence and symptom control throughout the day as well as decreased abuse potential. 120 Non-stimulants (e.g., alpha adrenergic agents and atomoxetine (A TX)) have also been developed and found to be helpful in controlling symptoms with few adverse events. 121 However, in general, the benefits of medications wear off when they are discontinued. Since ADHD is a chronic disorder, many children, teens, and adults stay on medications for years at a time. Given the possibility of cumulative effects over time, a review of evidence regarding benefits and risks of prolonged medication use for ADHD is indicated. Nonpharmacological Interventions In the area of nonpharmacologic interventions, behavior training has been found to be helpful, primarily for disruptive behaviors that frequently coincide with ADHD. 122 Since ADHD may begin before school age, using the precedent of older children, increasing numbers of preschoolers are being identified and treated, sometimes with medications. However, the most commonly used psychostimulant, MPH, does not yet have government regulatory approval for use in children less than 6 years of age, while MAS has been granted aEproval by the FDA in the United States for children under 6 years, but older than 3 years of age. 2 Recent reviews of treatments for preschoolers with ADHD emphasize the use of parenting interventions prior to medication based on general clinical consensus. 124 Indeed, the Preschool ADHD Treatment Study (PATS), funded by the U.S. National Institute for Mental Health (NIMH), included parent behavior training (PBT) as the first phase for all children recruited into the study prior to randomization for the purpose of evaluating efficacy and safety of psychostimulant medication. 125 While the few studies available suggest stimulant medications are effective for the core symptoms of inattention, hyperactivity, and impulsiveness in very young children, psychostimulants also appear to cause more adverse events in preschool children than in older children. 5 4 Beyond the PATS, little information exists to document effectiveness of either medication or non-medication interventions specifically for ADHD in this age group. Part of the difficulty has been lack of clarity regarding reliability and validity of diagnostic criteria and therefore lack of widespread application of the ADHD diagnosis for children under 6 years.n 9 4