PMID: 29558081
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Structured Abstract
Objectives:
Attention deficit hyperactivity disorder (ADHD) is a common pediatric neurobehavioral disorder often treated in the primary care setting. This systematic review updates and extends two previous Agency for Healthcare Research and Quality (AHRQ) systematic evidence reviews and focuses on the comparative effectiveness of methods to establish the diagnosis of ADHD, updates the comparative effectiveness of pharmacologic and nonpharmacologic treatments, and evaluates different monitoring strategies in the primary care setting for individuals from birth through 17 years of age.
Data sources:
We searched PubMed®, Embase®, PsycINFO®, and the Cochrane Database of Systematic Reviews for relevant English-language studies published from January 1, 2011, through November 7, 2016.
Review methods:
Two investigators screened each abstract and full-text article for inclusion, abstracted the data, and performed quality ratings and evidence grading. Random-effects models were used to compute summary estimates of effects when sufficient data were available for meta-analysis.
Results:
Evidence was contributed from 103 articles describing 90 unique studies. Twenty-one studies related to diagnosis, 69 studies related to treatment, and no studies were identified on monitoring. The Attention and Executive Function Rating Inventory and Childhood Executive Functioning Inventory performed better than the Cambridge Neuropsychological Test Automated Battery for the diagnosis of ADHD for ages 7–17 years (strength of evidence [SOE]=low). Evidence was insufficient on the use of electroencephalography (EEG) or neuroimaging to establish the diagnosis of ADHD for ages 7–17 years. No studies directly assessed the harms to children labeled as having ADHD. Limited additional evidence published since the original 2011 report was available on ADHD medications approved by the Food and Drug Administration (FDA) compared with placebo or compared to different FDA-approved ADHD medications (SOE=insufficient). For atomoxetine and methylphenidate, the most commonly reported adverse events were somnolence and mild gastrointestinal problems. Atomoxetine had slightly higher gastrointestinal effects than methylphenidate (SOE=low). Cognitive behavioral therapy improved ADHD symptoms (SOE=low). Child or parent training improved ADHD symptoms (SOE=moderate) but made no difference in academic performance (SOE=low). Omega-3/6 fatty acid supplementation made no difference in ADHD symptoms (SOE=moderate). Across all treatments, little evidence was reported on the risk of serious adverse events, including cardiovascular risk.
Conclusions:
The 2011 AHRQ systematic review highlighted the benefit of psychostimulants for children 6–12 years of age with ADHD for up to 24 months and found that adding psychosocial/behavioral interventions to psychostimulants is more effective than psychosocial/behavioral interventions alone for children with ADHD and oppositional defiant disorder. This targeted update found insufficient evidence regarding new approaches to the diagnosis (e.g., EEGs, neuroimaging). Little is known about the impact of being labeled as having ADHD. Although cognitive behavioral therapy or child or parent training may decrease symptoms of ADHD, more information is needed regarding the relative benefit of these approaches compared to, or combined with, medication treatment. Omega-3/6 supplementation does not appear to improve ADHD outcomes. No information was identified regarding the optimal strategy for monitoring after diagnosis.
Contents
- Preface
- Acknowledgments
- Key Informants
- Technical Expert Panel
- Peer Reviewers
- Introduction
- Methods
- Results
- Discussion
- References
- Acronyms and Abbreviations
- Appendix A. Exact Search Strings
- Appendix B. Data Abstraction Elements
- Appendix C. List of Included Studies
- Appendix D. List of Excluded Studies
- Appendix E. Key to Included Primary and Companion Articles
- Appendix F. Characteristics of Included Studies
- Appendix G. Overview of Included Studies
- Appendix H. Data Tables
Suggested citation:
Kemper AR, Maslow GR, Hill S, Namdari B, Allen LaPointe NM, Goode AP, Coeytaux RR, Befus D, Kosinski AS, Bowen SE, McBroom AJ, Lallinger KR, Sanders GD. Attention Deficit Hyperactivity Disorder: Diagnosis and Treatment in Children and Adolescents. Comparative Effectiveness Review No. 203. (Prepared by the Duke University Evidence-based Practice Center under Contract No. 290-2015-00004-I.) AHRQ Publication No. 18-EHC005-EF. Rockville, MD: Agency for Healthcare Research and Quality; January 2018. Posted final reports are located on the Effective Health Care Program search page. DOI: https://doi.org/10.23970/AHRQEPCCER203.
This report is based on research conducted by the Duke Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2015-00004-I). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report.
The information in this report is intended to help health care decisionmakers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.
AHRQ or U.S. Department of Health and Human Services endorsement of any derivative products that may be developed from this report, such as clinical practice guidelines, other quality enhancement tools, or reimbursement or coverage policies, may not be stated or implied.
This report may periodically be assessed for the currency of conclusions. If an assessment is done, the resulting surveillance report describing the methodology and findings will be found on the Effective Health Care Program Web site at www.effectivehealthcare.ahrq.gov. Search on the title of the report.
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