National Institutes of Health Consensus Development Conference Statement: Diagnosis and Treatment of Attention-Deficit/Hyperactivity Disorder (ADHD)

doi:10.1097/00004583-200002000-00018

Journal of the American Academy of Child & Adolescent Psychiatry

Volume 39, Issue 2, February 2000, Pages 182-193

https://doi.org/10.1097/00004583-200002000-00018 Get rights and content

ABSTRACT

Attention-deficit/hyperactivity disorder (ADHD) is a commonly diagnosed behavioral disorder of childhood that represents a costly major public health problem. Despite progress, ADHD and its treatment have remained controversial, especially the use of psychostimulants for both short- and long-term treatment. Although an independent diagnostic test for ADHD does not exist, there is evidence supporting the validity of the disorder. Studies (primarily short-term, approximately 3 months), including randomized clinical trials, have established the efficacy of stimulants and psychosocial treatments for alleviating the symptoms of ADHD and associated aggressiveness and have indicated that stimulants are more effective than psychosocial therapies in treating these symptoms. Because of the lack of consistent improvement beyond the core symptoms and the paucity of long-term studies (beyond 14 months), there is a need for longer-term studies with drugs and behavioral modalities and their combination. Although trials are under way, conclusive recommendations concerning treatment for the long term cannot be made at present. There are wide variations in the use of psychostimulants across communities and physicians, suggesting no consensus regarding which ADHD patients should be treated with psychostimulants, and thus the need for improved assessment, treatment, and follow-up. Furthermore, the lack of insurance coverage, preventing the appropriate diagnosis and treatment of ADHD, and the lack of integration with educational services are substantial barriers and represent considerable long-term costs for society. Finally, after years of clinical research and experience with ADHD, knowledge about the cause or causes of ADHD remain largely speculative. Consequently, there are no documented strategies for the prevention of ADHD.

Section snippets

What Is the Scientific Evidence to Support ADHD as a Disorder?

The diagnosis of ADHD can be made reliably using well-tested diagnostic interview methods. However, as of yet, there is no independent valid test for ADHD. Although research has suggested a central nervous system basis for ADHD, further research is necessary to firmly establish ADHD as a brain disorder. This is not unique to ADHD, but applies as well to most psychiatric disorders, including disabling diseases such as schizophrenia. Evidence supporting the validity of ADHD includes the long-term

SUPPORTING LITERATURE

The speakers listed above identified the following key references in developing their presentations for the consensus conference. A more complete bibliography prepared by the National Library of Medicine (NLM) at the NIH, along with the references below, was provided to the consensus panel for their consideration. The full NLM bibliography is available at the following Web site: http://www.nlm.nih.gov/pubs/cbm/adhd.html

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Cited by (274)

Non-pharmacological treatment of Attention Deficit Disorder with or without Hyperactivity (ADHD). Overview and report of the first international symposium on the non-pharmacological management of ADHD
2024, Encephale
Attention Deficit Disorder with or without Hyperactivity (ADHD is a neurodevelopmental disorder which affects the day-to-day functioning of children and adults with this condition. Pharmacological treatment can reduce the symptoms associated with ADHD, but it has some limitations. The objective of this symposium is to determine the effects of non-pharmacological approaches on ADHD symptoms. Results indicate that the following intervention are promising approaches: cognitive behavioral therapy (CBT), mindfulness-based interventions (MBI), yoga, cognitive and metacognitive intervention, neurofeedback and parental training programs. Current research advocates multimodal approaches in conjunction with school or work accommodations integrating innovative technologies.
Le Trouble Déficit de l’Attention avec ou sans Hyperactivité (TDAH) est un trouble neurodéveloppemental qui affecte le fonctionnement au quotidien des enfants et des adultes qui présente ce trouble. Un traitement pharmacologique permet de diminuer les symptômes associés au TDAH mais présente certaines limites. L’objectif de ce symposium est de déterminer les effets sur les symptômes liés au TDAH des approches non pharmacologiques. Les résultats sont prometteurs pour les approches suivantes : la thérapie cognitive et comportementale (TCC), les interventions thérapeutiques axées sur la pleine conscience, le yoga, les interventions cognitives et métacognitives, le neurofeedback, ainsi que les programmes ciblant les habilités parentales. Les recherches actuelles préconisent des approches multimodales réalisées conjointement à la mise en place d’aménagements en milieu scolaire ou professionnel et intégrant l’apport des technologies innovantes.
Opposite Control of Excitatory and Inhibitory Synapse Formation by Slitrk2 and Slitrk5 on Dopamine Neurons Modulates Hyperactivity Behavior
2020, Cell Reports
Citation Excerpt :
Attention deficit/hyperactivity disorder (ADHD) is characterized by symptoms of inattention and/or hyperactivity/impulsivity that interfere with the functioning or development of the brain (NIH, 2000).
The neurodevelopmental origin of hyperactivity disorder has been suggested to involve the dopaminergic system, but the underlying mechanisms are still unknown. Here, transcription factors Lmx1a and Lmx1b are shown to be essential for midbrain dopaminergic (mDA) neuron excitatory synaptic inputs and dendritic development. Strikingly, conditional knockout (cKO) of Lmx1a/b in postmitotic mDA neurons results in marked hyperactivity. In seeking Lmx1a/b target genes, we identify positively regulated Slitrk2 and negatively regulated Slitrk5. These two synaptic adhesion proteins promote excitatory and inhibitory synapses on mDA neurons, respectively. Knocking down Slitrk2 reproduces some of the Lmx1a/b cKO cellular and behavioral phenotypes, whereas Slitrk5 knockdown has opposite effects. The hyperactivity caused by this imbalance in excitatory/inhibitory synaptic inputs on dopamine neurons is reproduced by chronically inhibiting the ventral tegmental area during development using pharmacogenetics. Our study shows that alterations in developing dopaminergic circuits strongly impact locomotor activity, shedding light on mechanisms causing hyperactivity behaviors.
Assessment of comorbidity and social anxiety in adolescents with attention deficit hyperactivity disorder: the SELFIE study
2019, Anales de Pediatria
El trastorno por déficit de atención con hiperactividad (TDAH) y su comorbilidad repercuten en la ansiedad social de niños y adolescentes, no obstante, apenas hay estudios que aborden este tema en la adolescencia. El objetivo era evaluar el grado de ansiedad social y analizar la presencia de comorbilidades psiquiátricas (CPS).
Estudio observacional transversal en el que se incluyeron pacientes de 12-18 años con diagnóstico confirmado de TDAH (DSM-5). Se recogió información sobre la presencia y tipo de CPS y se evaluó la ansiedad social mediante la escala Social Anxiety Scale for Adolescents (SAS-A).
Participaron 46 especialistas de psiquiatría del niño y del adolescente o neuropediatría, que incluyeron a 234 pacientes. El 68,8% (159) eran varones y el 31,2% (72) mujeres, con edad media de 14,9 años (IC 95%: 14,6-15,1). El 51,7% (121) tenía TDAH de tipo combinado (TC), el 37,2% (87) con predominio del déficit de atención (TDA) y el 9% (21) con predominio hiperactivo-impulsivo (TH). El 97,9% (229 pacientes) recibía tratamiento farmacológico: metilfenidato en el 78,6% (184), lisdexanfetamina en el 15% (35) y atomoxetina en el 4,3% (10).
El 50,4% (118) presentaba alguna CPS, con predominio de los trastornos del aprendizaje y de la comunicación (47, 20,1%) y los trastornos de ansiedad (45, 19,2%). Se observó un grado de ansiedad social significativamente mayor en comparación con los valores normales de la escala en la población sana. Los adolescentes con TDA presentaron peores puntuaciones en la escala SAS-A en comparación con adolescentes con TH (p = 0,015). La presencia de trastornos de ansiedad comórbidos se relacionó con peores puntuaciones en la escala SAS-A, reflejando una mayor ansiedad social en estos pacientes (p < 0,001).
Los adolescentes con diagnóstico de TDA y aquellos con comorbilidades psiquiátricas de tipo ansiedad presentaron un mayor grado de ansiedad social según su puntuación en la escala SAS-A. Este aspecto psicológico debería ser detectado y controlado en los adolescentes con TDAH para favorecer su adaptación social.
Attention-deficit/hyperactivity disorder (ADHD) and its comorbidities have an impact on the social anxiety of children and adolescents, but there are practically no studies addressing this topic in adolescence. Our objective was to assess the degree of social anxiety and to analyse the presence of psychiatric comorbidities (PSCs) in adolescents with ADHD.
We conducted a cross-sectional observational study in patients aged 12 to 18 years with a confirmed diagnosis of ADHD (DSM-5). We collected data on the presence and type of PSCs and assessed social anxiety by means of the Social Anxiety Scale for Adolescents (SAS-A).
Forty-six child and adolescent psychiatrists and paediatric neurologists participated in the study and recruited 234 patients. Of the total patients, 68.8% (159) were male and 31.2% (72) female, with a mean age in the sample of 14.9 years (95% CI, 14.6-15.1). The type of ADHD was combined type (C) in 51.7% (121), predominantly inattentive (PI) in 37.2% (87), and predominantly hyperactive-impulsive (PH) in 9% (21). Of all patients, 97.9% (229) received pharmacological therapy: 78.6% (184) methylphenidate, 15% (35) lisdexamfetamine and 4.3% (10) atomoxetine.We found PSCs in 50.4% of the patients (118), of which the most frequent were learning and communication disorders (20.1%, n = 47) and anxiety disorders (19.2%, n = 45). The patients scored significantly higher in the SAS-A compared to reference values in the healthy population. The scores in the SAS-A were less favourable in adolescents with the PI type compared to those with the PH type (P = .015). The presence of a comorbid anxiety disorder was associated with worst scores in SAS-A (P < .001) showing an increased social anxiety.
Adolescents with ADHD classified as PI and those with comorbid anxiety had a higher degree of social anxiety as measured by the SAS-A. This psychological aspect must be identified and controlled in adolescents with ADHD to promote their social adaptation.
Long-term challenge of methylphenidate changes the neuronal population and membrane property of dopaminergic neuron in rats
2019, Neurochemistry International
Attention deficit hyperactivity disorder (ADHD) has a prevalence of 7.5% in school-age children in Taiwan. A number of ADHD patients start taking medications in elementary school and continue their treatment until they are in college or adulthood. Methylphenidate is the most frequently used medication prescribed for ADHD treatment. The influence of long-term treatment of methylphenidate on neuro-development, especially dopaminergic neurons, in rats would be explored. This study investigated the impact of long-term treatment of methylphenidate on different neurons. Rats aged 1 month were divided into three groups: Normal group receiving only sucrose solution, Low-dose group receiving 2 mg/kg methylphenidate, and High-dose group receiving 10 mg/kg methylphenidate; for each group, the drug was administrated twice per day. After 7 months of the treatment period, then the alterations in number of norepinephrine, serotonergic, cholinergic and dopaminergic neurons were quantified. The number of dopaminergic neurons in the substantia nigra (SN), the serotonergic neurons in the dorsal raphe nucleus, and the cholinergic neurons in the tegmental nucleus significantly decreased as compared with Normal group, whereas the noradrenergic neurons in the locus coeruleus substantially increased. The whole-cell recording was made from dopaminergic neurons residing in the SN for examination of their firing activity. The recorded dopaminergic neurons in SN were categorized into slow and fast firing using 10 Hz as a classified index. The results displayed that the ratio of dopaminergic neurons with fast firing in the High-dose group was less as compared with those in the Normal and the Low-dose group. Furthermore, the amplitude of action potential of the dopaminergic neurons with slow firing was higher in the High-dose group than those in the Normal and Low-dose groups. The firing behavior of dopaminergic neurons and dopamine concentration in the brain is affected by the long-term challenge of methylphenidate.
Boredom proneness and its correlation with Internet addiction and Internet activities in adolescents with attention-deficit/hyperactivity disorder
2018, Kaohsiung Journal of Medical Sciences
This study examined the associations of boredom proneness with Internet addiction and activities as well as the moderators for such associations in adolescents with attention-deficit/hyperactivity disorder (ADHD). In total, 300 adolescents with ADHD participated in this study. Their Internet addiction, the scores for lack of external and internal stimulation on the Boredom Proneness Scale-short form (BPS-SF), ADHD, parental characteristics, and the types of Internet activities were examined. The associations of boredom proneness with Internet addiction and Internet activities and the moderators of the associations were examined using logistic regression analyses. Higher scores for lack of external stimulation on the BPS-SF were significantly associated with a higher risk of Internet addiction. Maternal occupational socioeconomic status moderated the association of lack of external stimulation with Internet addiction. Higher scores for lack of external stimulation were significantly associated with a high tendency to engage in online gaming, whereas higher scores for lack of internal stimulation were significantly associated with a low tendency to engage in online studies. Lack of external stimulation on the BPS-SF should be considered a target in prevention and intervention programs for Internet addiction among adolescents with ADHD.
Neurocognitive effects of methylphenidate in adults with attention-deficit/hyperactivity disorder: A meta-analysis
2018, Neuroscience and Biobehavioral Reviews
Citation Excerpt :
Use of stimulants is increasing rapidly among adults, with 53% more adults using stimulants in 2012 than in 2008 (Express Scripts, 2014). The most researched of these medications is methylphenidate (MPH) (National Institutes of Health Consensus Development Conference Statement, 2000). MPH increases the amount of dopamine and norepinephrine that are available in the synapse by blocking reuptake (Krause et al., 2003; Pietrzak et al., 2006).
PIEVSKY, M. A., and R. E. McGrath. Neurocognitive effects of methylphenidate in adults with attention-deficit/hyperactivity disorder: A meta-analysis…NEUROSCI BIOBEHAV REV 81(1) XXX-XXX, 2017.- This meta-analysis summarized 21 double-blind randomized controlled trials with a mean study duration of 18 days comparing the neurocognitive functioning of adults with attention-deficit/hyperactivity disorder (ADHD) on methylphenidate vs placebo. Effect sizes were weighted using a random-effects model. Scores on neurocognitive measures and tests of driving ability were on average higher on methylphenidate than on placebo, g = 0.17, p < .01, 95% CI = [0.05, 0.28], with little heterogeneity, Q(20) = 15.05, p = .77, I² = 0. Performance on methylphenidate was significantly better than on placebo for the following domains: working memory (mean g = 0.13, 95% CI = [0.00, 0.26]), reaction time variability (0.16, [0.03, 0.28]), vigilance (0.22, [0.11, 0.33]), driving (0.22, [0.10, 0.34]), and response inhibition (0.23, [0.10, 0.36]). Quantitative and qualitative assessment revealed evidence of publication bias. Summarizing across studies, methylphenidate improved the performance of adults with ADHD on neurocognitive measures and tests of driving, suggesting that methylphenidate is an effective treatment for adults with ADHD and can improve processes related to attention and concentration.

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This conference was held November 16-18, 1998.

NIH Consensus Statements are prepared by a nonadvocate, non-Federal panel of experts, based on (1) presentations by investigators working in areas relevant to the consensus questions during a 2-day public session; (2) questions and statements from conference attendees during open discussion periods that are part of the public session; and (3) closed deliberations by the panel during the remainder of the second day and morning of the third. This statement is an independent report of the panel and is not a policy statement of the NIH or the Federal Government.

NIH Consensus Development Panel members' names and affiliations are listed at the end of the text. Planning Committee members' names may be found at the following Web site: http://odp.od.nih.gov/consensus/cons/110/110_intro.htm.

Correspondence to John H. Ferguson, M.D., National Institutes of Health, 31 Center Drive, MSC-2082, Bethesda, MD 20892.

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SPECIAL COMMUNICATIONNational Institutes of Health Consensus Development Conference Statement: Diagnosis and Treatment of Attention-Deficit/Hyperactivity Disorder (ADHD)

ABSTRACT

Section snippets

What Is the Scientific Evidence to Support ADHD as a Disorder?

SUPPORTING LITERATURE

SPECIAL COMMUNICATION
National Institutes of Health Consensus Development Conference Statement: Diagnosis and Treatment of Attention-Deficit/Hyperactivity Disorder (ADHD)