Research in Attention Deficit /Hyperactivity Disorder (ADHD) has, for many decades, been dominated by a focus on measuring and improving its core symptoms. However, a new conceptual direction has been developing that focuses on measuring and seeking ways to improve function, both overall and in specific academic, social, and other domains that have major impacts on the lives of children and their families. In tandem with this shift toward function is a new treatment goal that goes beyond improvement of symptoms to full remission of impairment.
No standardized research definition of remission of childhood ADHD has been established, but in the well-known Multimodal Treatment of ADHD (MTA) study,
1,
2 “treatment success” was defined as a clinically satisfactory response of near normalization (operationally defined as an item mean ≤ 1.0 on a composite of parent and teacher Swanson, Nolan, and Pelham Scale [SNAP] ratings).
3 This is consistent with the
Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV),
4 which specifies that for the diagnosis of ADHD, the pattern of inattention and/or hyperactivity/impulsivity must be more frequent and severe than is typical for those at similar developmental levels, as judged by two sources. Thus, items which score 0 (“not at all”) or 1 (“just a little”) would not qualify as ADHD symptoms. It is also consistent with the norms developed for the SNAP rating scale, which show that most schoolchildren score within the 0 to 1 range and do not display the psychopathological features that are DSM-IV criteria for ADHD.
5 An alternative statistical procedure
6 that uses the midpoint between clinical and control group scores as the cutoff (item mean ≤ 1.2) yielded very similar results.
In the MTA study, 88% of a local normal comparison group had scores below this cutoff, while after 14 months, this level was achieved by
- 25% of children with ADHD who had received usual care in the community
- 34% of patients receiving highly intensive behavioural interventions but no medications
- 56% of those receiving only medications in regimens that were considered optimum at the time of the study, and
- 68% of those children with ADHD receiving both medication and behavioural interventions ().7
Thus, even with a rigorous multimodal intervention, over 30% of the ADHD patients in the MTA study did not reach remission.
Long-acting stimulant formulations have dramatically changed the landscape of ADHD practice. At the most recent annual meeting of the Canadian Academy of Child and Adolescent Psychiatry (Montreal, Quebec; October 4, 2004), a symposium explored the impact of these medications on broader outcomes for children with ADHD.
Dr James Swanson discussed the rationale and development of the drugs and their appropriate dosing, while Dr Lily Hechtman reviewed the results of new clinical studies demonstrating the efficacy of long-acting stimulants on parameters of overall and specific functioning (eg, driving performance). We hope that this summary of the proceedings and highlights of their presentations will be useful to practitioners who are eager to improve outcomes for their young ADHD patients.
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