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nih consensus statement

Diagnosis and Treatment of Attention Deficit Hyperactivity Disorder

In November 1998, the National Institutes of Health held a three and a half day conference of non-advocate, non-federal experts with the goal of establishing a professional consensus on a number of questions surrounding ADHD, including:

  • What is the scientific evidence to support ADHD as a disorder?

  • What is the impact of ADHD on individuals, families, and society?

  • What are the effective treatments for ADHD?

  • What are the risks of the use of stimulant medication and other treatments?

  • What are the existing diagnostic and treatment practices, and what are the barriers to appropriate identification, evaluation, and intervention?

  • What are the directions for future research?
Over the course of two days, thirty-one experts presented their research findings before the consensus panel and an audience of over 1,000. Then the consensus panel, which consisted of 13 experts representing the fields of psychology, psychiatry, neurology, pediatrics, epidemiology, biostatistics, education, and the public, wrote and presented a draft of a consensus statement to for discussion and refinement. Despite some criticism of the consensus process, the final version remains the most comprehensive and unbiased evaluation of ADHD and its treatments to date.

Conclusions of the Consensus Panel [emphasis added]:

"Attention deficit hyperactivity disorder or ADHD is a commonly diagnosed behavioral disorder of childhood that represents a costly major public health problem. Children with ADHD have pronounced impairments and can experience long-term adverse effects on academic performance, vocational success, and social-emotional development which have a profound impact on individuals, families, schools, and society. Despite progress in the assessment, diagnosis, and treatment of ADHD, this disorder 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. Further research is needed on the dimensional aspects of ADHD, as well as the comorbid (coexisting) conditions present in both childhood and adult forms.

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 presently.

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. These problems point to the need for improved assessment, treatment, and followup of patients with ADHD. A more consistent set of diagnostic procedures and practice guidelines is of utmost importance. 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, our knowledge about the cause or causes of ADHD remains largely speculative. Consequently, we have no documented strategies for the prevention of ADHD."

Read the whole Consensus Statement on the NIH web site.

links

Abstracts of many of the conference presentations are available online from about.com. Some that are particularly interesting:
Overview of Attention Deficit Hyperactivity Disorder
C. Keith Conners, Ph.D., M.A.
This introduction provides a brief history of ADHD and its changing definitions, and highlights ongoing areas of research into treatment methods and risk factors.
Biological Bases of Attention Deficit Hyperactivity Disorder: Neuroanatomy, Genetics, and Pathophysiology
James Swanson, Ph.D., and F. Xavier Castellanos, M.D.
A review of recent pivotal studies from neuroanatomy and molecular biology.
Stimulant Medications
Dr. Lawrence Greenhill reviews the research on the rates of stimulant prescription, and the studies on short and long term efficacy and risks of the stimulant treatment.
Is Attention Deficit Hyperactivity Disorder a Valid Disorder?
William B. Carey, M.D.
Carey argues that ADHD as currently defined is not a valid disorder. He claims, among other things, that ADHD symptoms are not clearly distinguishable from normal temperament variations among children, and that the DSM-IV definition mistakenly ignores the role of the child's environment in creating behavioral problems.
The Prevalence and Cross-Cultural Validity of Attention Deficit Hyperactivity Disorder
Hector R. Bird, M.D.
This is a review of cross-cultural epidemiological studies. Despite the fact that the rate of ADHD diagnosis rates vary widely--from 1 percent to 20 percent of the population - among different cultures, the reviewers found that in general, "the overall syndrome repeatedly shows high internal consistency across settings. When behavior questionnaires are subjected to factor analytic procedures, the results are invariably similar across cultural settings as disparate as the United States, Italy, China, Germany, Brazil, and Thailand. These analyses repeatedly show a syndrome that breaks down into two robust factors of inattention and hyperactivity/impulsivity."


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