Diagnosis and management of ADHD: a new way forward?
Abstract: Attention deficit hyperactivity disorder (ADHD) is a condition characterised by a persistent pattern of inattention or hyperactivity. The condition impacts on multiple aspects of an individual's life, as it can affect motor skills, social relationships, self-esteem and educational success. The diagnosis and management of this condition is of concern to healthcare professionals and is a topic often debated by the media. The most recent National Institute for Health and Clinical Excellence (NICE) guidance on diagnosing and managing ADHD in children, young people and adults has triggered a resurgence of this debate. The NICE guidance is particularly interesting because it states that behavioural therapies, rather than medications, should be the first-line treatment. While this apparent reversal in approach will be welcomed by some, this is an emotive issue and will no doubt also meet with strong opposition. This paper seeks to explore and discuss the existing evidence relating to medication versus behavioural therapies, and difficulties that may arise in implementing the latest NICE guidance.

Key words

ADHD, children and young people, NICE guidance, Ritalin, behaviour therapy
Article Type: Report
Subject: Attention-deficit hyperactivity disorder (Care and treatment)
Attention-deficit hyperactivity disorder (Diagnosis)
Attention-deficit hyperactivity disorder (Patient outcomes)
Behavior therapy (Patient outcomes)
Behavior therapy (Comparative analysis)
Stimulants (Dosage and administration)
Stimulants (Comparative analysis)
Stimulants (Patient outcomes)
Drug therapy (Comparative analysis)
Drug therapy (Patient outcomes)
Author: Brimble, Mandy J.
Pub Date: 10/01/2009
Publication: Name: Community Practitioner Publisher: Ten Alps Publishing Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2009 Ten Alps Publishing ISSN: 1462-2815
Issue: Date: Oct, 2009 Source Volume: 82 Source Issue: 10
Topic: Canadian Subject Form: Behaviour therapy; Behaviour therapy
Product: Product Code: 2834260 Stimulant Preparations NAICS Code: 325412 Pharmaceutical Preparation Manufacturing SIC Code: 2833 Medicinals and botanicals; 2834 Pharmaceutical preparations
Geographic: Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom
Accession Number: 209163256
Full Text: Introduction

Recent National Institute for Health and Clinical Excellence (NICE) guidance for the diagnosis and management of attention deficit hyperactivity disorder (ADHD) in children, young people and adults, (1) has attracted media attention and reignited the debate surrounding treatment of the condition. Previous NICE guidance acknowledged the role of alternatives such as behaviour therapy, but recommended that use of medication should not be postponed if such provision was not available or was subject to delay. (2) The latest guidance appears to almost completely reverse the previously recommended approach, with behavioural therapies being promoted as a first-line treatment while medications such as methylphenidate (Ritalin) are recommended for use in severe cases only.

Those who believe that ADHD is over-diagnosed and drug treatments overused will welcome this guidance. Nevertheless, it will inevitably be difficult to implement, as many parents who feel that the medication regime is working for their child will be reluctant, if not resistant, to altering or abandoning it. In addition, parents whose child is newly diagnosed are likely to be aware of the trend for treatment with medication, and to therefore have expectations that their treatment regime will follow a similar path. Since parental understanding has unsurprisingly been shown to affect compliance with treatment for ADHD, whatever that treatment may be, (3) there will certainly be a need for a widespread educational programme in order to effect this change of approach.

There are many who will argue that the motivation behind this guidance is purely financial, bearing in mind that the use of methylphenidate and other stimulants used in treating ADHD cost the NHS 13 million [pounds sterling] in 2004. (2) Since the ethos of NICE is to examine effectiveness in relation to cost, it is inevitable that these criticisms may occur. However, in this instance it is likely that a redirection of funds rather than a reduction will be the result. The NICE document provides direction to tools and templates that enable the calculation of local costings and savings. (1) Nevertheless, facilitation of the transition is likely to require some additional interim funds in a number of areas--education, setting up satisfactory and sufficient behavioural therapy services to transfer patients into, monitoring mechanisms and continued availability of existing services and treatments for cases where the changeover of interventions is unsuccessful.

This paper seeks to examine evidence that supports differing approaches to the treatment of ADHD. The aim is to provide a balanced view of how both medications and behavioural therapies may be utilised where they are most appropriate.


The condition of ADHD was originally described by William Still in 1902, and later classified for inclusion in the third edition of the Diagnostic and statistical manual of mental disorders (DSM-III) by Dr Robert Spitzer. (4) A more recent version of this manual (DSM-IV) (5) and the International classification of mental and behaviour disorders (10th revision) (ICD-10) (6) remain the recommended clinical standard for diagnosis. (1) In essence, these diagnostic tools consist of a behaviour checklist through which the patient is deemed to have ADHD if they display a certain number of characteristics in a number of settings over a specified period of time.

While the most recent approach--of behavioural interventions as a first-line treatment for a condition diagnosed on the basis of a behavioural checklist--may appear more logical than the previous penchant for medication, issues relating to definite diagnosis and the role of stimulants remain. Although the recent NICE guidelines1 briefly acknowledge the existence of other means of diagnosis such as neuroimaging, they do not explore this fully or make recommendations for further research.

The use of stimulant drugs for the treatment of hyperactivity is not a modern phenomenon. A literature review published in 1977 that explored the efficacy of this practice referred to work dating back to 1937. (7) However, it is only fairly recently that research has identified why modern drug regimes are effective--that the cause of the condition may be linked to low dopamine levels in the brain (8) and that these levels are increased by stimulants such as methylphenidate. (9) Neuroimaging has been instrumental in fuelling conjecture that the cause of lower dopamine levels is abnormality in the striatal region of the brain (10) and there are many on-going research projects that seek to explore this theory further, such as at the Laboratory of NeuroImaging, University of California, Los Angeles. If this proves to be the case, there would surely be an argument for treatment with stimulants based solely on a diagnosis of low dopamine levels.

The debate

Debate surrounding the increase in rates of diagnosis of ADHD and the subsequent prescription of medication has been prevalent both in academic literature (11,12) and the media. (13) However, others involved in supporting children and families affected by the condition dispute this and claim that ADHD is under-diagnosed in the UK and appropriate medication under-prescribed. (14)

While some writers give explanations for over-prescribing such as campaigning parents, the role of the media and the influence of drug companies, (15) other authors offer alternative explanations. For example, the increase in the prevalence of ADHD may actually be due to differences in the diagnostic criteria contained in DSMIV in comparison to DSM-III. (16) Such authors also acknowledge that the revised criteria may better reflect the heterogeneous nature of the condition. It could therefore be argued that prior to DSM-IV, (5) many children displaying symptoms that are now recognised as indicators for ADHD were undiagnosed because they did not meet the necessary criteria and could not consequently be treated appropriately. (16) One view that considers multiple factors states that the increase in diagnosis of ADHD is due to a combination of two factors--an increase in identification of the condition together with a change in 'sociological conditions' that give rise to disordered households, increased demands in school and the absence of support systems, such as the demise of extended family. (17) A bibliography and critical appraisal of systematic reviews and meta-analyses carried out in 1999 highlighted that these factors are usually overlooked during the assessment and diagnosis of ADHD. (18)

Claims of over-diagnosis and overprescribing (15) contradict earlier evidence that states that, while some children are diagnosed and treated without adequate evaluation, there is insufficient proof of extensive over- or misdiagnosis of ADHD or over-prescription of methylphenidate. (19)

It is clear from the literature that there is much contradictory evidence surrounding ADHD, which can only add to the confusion of parents, healthcare professionals, teachers and the public in general. Nevertheless, in a culture of evidence-based practice, it seems a little strange that although it seems possible that there may be an identifiable medical cause for ADHD, the latest guidance (1) barely mentions the role of neuroimaging and/or testing for dopamine levels in diagnosis. Neither does it recommend further research in this field. It has been acknowledged that the symptoms of ADHD are also present in other conditions caused by emotional rather than organic factors. (20) In addition, there is research that demonstrates that children who have coexisting conditions do not benefit from medication. (21) It could therefore be argued that medication may have been given needlessly to children who are already emotionally compromised, and that this would contravene the ethical principle of non-maleficence, especially since those opposed to the use of methylphenidate or similar drugs state that these treatments actually depress the child's personality and focus to such an extent that they are unable to misbehave or attend to more than one activity at a time. (22) An opposing argument is that behavioural therapy has not always been available due to shortfalls in provision (2) and that it would be contrary to the ethical principle of beneficence to delay giving medication while waiting for such therapy. However, some researchers state that stimulant medication has been prescribed even when alternatives are available. (19)

Behavioural therapies

As long as diagnosis of ADHD is based on a list of behaviours, it would seem reasonable that behavioural therapies are used as part of a frontline treatment. In this sense, the latest guidance (1) is extremely logical. However, in the current climate and culture of the 'quick fix' (23) it may be difficult to persuade parents that this is a viable option, particularly when the child's affected peers may be taking medication that appears to be effective. Some writers go so far as to suggest that a diagnosis of ADHD often has the effect of absolving parents of any responsibility for their child's difficult behaviour, (15,24) and this may also impact on success levels in changing expectations and compliance with new behaviour-based regimes.

In addition, many reviews that have aimed to examine the efficacy of behavioural therapies in comparison to medication have been inconclusive. For example, the Centre for Reviews and Dissemination examined a number of reviews (10,25,26) and found that it was difficult to assess the benefits of behavioural interventions, because the studies reviewed contained vast variations in terms of participants, interventions and outcomes, thus making it very difficult to draw definite conclusions from the results.

The effectiveness of behavioural therapies for a number of problems, including ADHD, has been examined at length (27) and four main approaches explored:

[*] Structured family therapy

[*] Parent training

[*] Coping skills training for children

[*] School-based behavioural programmes.

Family therapy is described as focusing on helping families to develop patterns of organisation that are helpful in managing children effectively. Parental co-operation and problem-solving is essential for this approach to be successful. Furthermore, it involves a clear demarcation of child and parent roles and responsibilities, advocating effective communication within a supportive family environment. Parent training involves helping parents to acquire skills that will enable them to objectively examine positive and negative behaviours displayed by the child and the events that immediately precede or follow. By examining influences on behaviours in this way, the training aims to help parents to be able to manipulate interactions and events so as to positively influence the child's behaviour. In relation to therapies that focus primarily on the child, either singly or as part of a multifaceted programme, the development of coping skills in the child--teaching them how to sustain attention and problem-solving techniques--are seen as key in reducing impulsivity and aggressive behaviour. (27)

Through home-school and parent-teacher liaison, the approaches described above can be extended into the school environment, thus maintaining consistency in the management of the child.

* Family therapy

Although some authors are positive about the effectiveness of behavioural approaches such as family therapy for the treatment of ADHD, they also stress the importance of combining them with the use of low doses of stimulants, referring to such combinations as 'multi-component treatment packages'. (27) Others claim that medication is 'superior' to behavioural therapy in addressing the core symptoms of the condition, and that even when medication and behaviour therapy are combined they are still no better than medication alone. (28) However, these authors have recognised that there was a reduction in undesirable behaviours in all the groups studied, and the data collected was based on parents' and teachers' ratings. It could be argued that parents and teachers are not necessarily the most objective of data collectors, since they already have a relationship with the child and could therefore be influenced by this.

The above research (28) was one of two studies examined for a Cochrane Review conducted in 2005. (29) The reviewers' literature search considered 24 other studies for inclusion, but they were excluded on various grounds, primarily lack of a control group. The only other study that was found to be suitable for inclusion found that family therapy treatment was slightly better than a medication placebo. (30) The collection of data in this study was conducted in a similar way to that described above, (28) so the same criticisms apply. The Cochrane Review recommend that further research is needed to ascertain whether family therapy is an effective intervention for ADHD, and that this research should compare the success of family therapy in comparison to a no-treatment control group. (29) Although this would be the ideal, it is difficult to see how ethical approval would be obtained, as it would be unethical to deny therapies to children suffering from symptoms that have led to a diagnosis of ADHD. In addition, if the control group was to receive a placebo, it would be difficult to achieve this and any 'pretend' family therapy could have an unintentional positive or negative effect, thus negating the results.

A follow up of one of the above studies (28) aimed to investigate the long-term effects of medication alone, behavioural therapy alone, a combination of medication and behavioural therapy, and usual community care. (31) However, the treatment period was only an initial 14 months, and these findings indicate choices made following the initial 'treatment' period rather than the long-term effects of these continued interventions. The findings show that the advantage of medication therapy--over a 14-month period--demonstrated in the earlier study was no longer evident after a total of 36 months. The authors state that a decline in ADHD symptoms, changes in medication or breaks in treatment could account for this. They also acknowledge that factors not yet evaluated could also be of influence. Their observation that those who were on the behavioural programme only were more likely to start taking medication once the 14-month programme stopped suggests that these participants viewed medication as a better option (possibly influenced by the report of the earlier study). This finding may also merely illustrate that a trend for the 'quick fix' is likely to prevail in the absence of any widely available and accessible alternatives. (32)

An on-going study is investigating the effects of a patient and family education programme for children and adolescents with ADHD. (33) Although this evaluation focuses on education rather than therapy, its findings once published may be useful in informing the debate around this type of family-based intervention.

It is clear that robust evidence that demonstrates the efficacy or otherwise of family therapy is scarce, and further studies need to be undertaken. However, funding for such studies may be problematic. It is likely that large drug companies, who have a vested interest in the continued use of stimulants, will gladly fund research into neuroimaging that may legitimise them, while funding available to examine behavioural therapies may be much less readily available.

Parent training

Parent training is seen as a means of facilitating supportive measures that aim to empower parents to accept their responsibilities. 24 In common with other research relating to behavioural therapies for ADHD, that which examines parent training is primarily inconclusive. For example, a systematic review examining the effectiveness of interventions for children aged six to 12 years with externalising behavioural disorders such as ADHD found that parent training and community-based interventions may be beneficial, but also highlighted the efficacy of medication.34 Along with many others, they recommend further research into specific interventions.

A literature review of behavioural parent training studies found it to be an effective method of treating the condition, but that it remained largely under-researched in terms of the wide range of factors that may influence incidence and therefore be relevant to interventions. (32) The review gives a useful overview of the components of parent training programmes, (32) which include education about the condition, diaries and checklists, ignoring minor bad behaviour and attending to appropriate behaviour, commands and reprimands, rules, timeout, reward/cost, enforcing contingencies for outside the home, problem-solving and maintenance of the programme. The review examined 28 studies that included 1161 treated children, primarily using parent ratings of problem behaviour as the measure of success or otherwise. (32) It could be suggested that parental perception may be influenced by their feelings about behavioural therapy and their expectations of its likely effects. However, it could also be argued that a parent knows the child better than any other person and therefore may identify very small changes that may not be noticed by an objective, unrelated observer. Some of the studies included other interventions carried out in the school environment, (32) and although these were few, they may have influenced the results relating to parent training. In terms of resourcing this type of intervention, one useful finding of the study was that group-based activities were comparable to individual sessions and additionally beneficial as they facilitated increased total therapist time with families, peer support and decreased stigmatisation. (32) However, the authors recognise that individual interventions would be preferable for families with more severe psychopathology.

Despite previous acknowledgement of the effectiveness of parent training or education programmes by NICE and publication of guidance on their use in the management of children with conduct disorders (often associated with ADHD), (35) these programmes are not recommended as 'first-line' treatment. The recommendation within this document (35)--that programmes should have proved effectiveness, but that this should not be confined to randomised controlled trials (RCTs) and could relate to other rigorous independent evaluation methods, such as audit--was the likely catalyst for this change in direction. Previous systematic reviews had often excluded valid forms of evaluation because they were not RCTs, and these other means of evaluation often report positive outcomes from behaviour interventions whereas RCTs are less positive. (26) This had previously resulted in a bias in the evidence that is deemed to be credible. It is likely that by following their own guidance, (35) NICE has now considered evidence that it had previously deemed to be unreliable, and that this has resulted in the dramatic change in direction with regard to first-line treatment. (1)

Conclusion and recommendations In an effort to avoid a blame culture, it is possible that a medical approach has been adopted with all children who demonstrate certain behaviours, rather than seeking to ascertain, without question, the specific and actual cause. Some argue that medication is a 'quick fix' that does not enable or empower the child or family to take an active role in the management of behaviour. (22) Depending on research relating to neuro-imaging and dopamine-level testing, the future may bring a definitive scientific diagnosis of ADHD that would provide a clearer basis for treatment with medication or behavioural therapy. This would provide practitioners with a marker on which to base their choice of treatment options and clarify the nature of the child's difficulties for both themselves and their parents or carers.

In the meantime, the latest NICE guidelines (1) promote a change in approach to treating children who have ADHD, particularly those deemed to be less severely affected. The change in culture required to implement this guidance fully is huge. Prescribers are likely to find it difficult to persuade children and parents to alter or abandon medication regimes that are perceived as effective in favour of behavioural therapy. In addition, drug companies have the means to fund widespread research to legitimise continued use of medication for treatment of ADHD. However, the new guidelines may promote research into the area of behavioural therapy. At the very least, if they are implemented, the guidelines will lead to a greater population treated by behavioural therapy, thereby increasing the availability of research subjects among whom effectiveness may be measured.

Whatever the future holds, it is clear that the diagnosis, treatment and management of ADHD will continue to evolve in an interesting manner, and evoke emotive responses from healthcare professionals, children and their families and the general public.


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Key points

* Recent NICE guidance states that behavioural therapy rather than medication should be used as a first-line treatment approach for ADHD, in all but the most severe cases

* Historical 'trends' and expectations of treatment regimes will be difficult to change

* Transition to new first-line approaches will require wide-ranging educational programmes for healthcare professionals and patients

* Additional financial resources are likely to be required to facilitate the transition, both in terms of education and to fund dual treatments where crossover is being implemented

* These new recommendations may lead to an increase in the credible evidence base for treatment by behavioural therapy

Mandy J Brimble PGCE, NP, BSc, DipHe, RN

Lecturer and admissions tutor, Cardiff School of Nursing and Midwifery Studies, Cardiff University
Gale Copyright: Copyright 2009 Gale, Cengage Learning. All rights reserved.