cont. from

American Association of Pediatrics Clinical Practice Guideline:
Treatment of the School-Aged Child With Attention-Deficit/Hyperactivity Disorder

AREAS FOR FUTURE RESEARCH
Tailoring Treatments to Children and Outcomes

At the present time, the clinician's initial choice of a specific treatment program—the exact stimulant medication and the precise form of behavior therapy—is an area of uncertainty. Research to date has not shown clear advantages of one stimulant medication over others. The process of prescribing an effective and comprehensive plan based on the characteristics of the child and family and tailored in terms of type, intensity, and frequency would help clinicians to improve treatment plans. What is required is information relating specific sociodemographic characteristics (eg, age or sex) or clinical characteristics (eg, subtype of ADHD) to optimal responses to stimulant medication or type of behavior therapy. Moreover, relating treatments to specific behaviors or components of ADHD rather than the whole symptom complex would allow the clinician to better tailor the treatment plan.

Many children with ADHD have coexisting conditions, including anxiety, depression, oppositional defiant disorder, conduct disorder, and learning disabilities. The literature provides minimal information about how to treat these coexisting conditions in conjunction with ADHD and how the conditions affect the effectiveness and safety of treatments. Research on how ADHD and coexisting conditions interact to affect treatment and outcomes will help determine if children require multiple concurrent treatments. Such studies can identify sensible, effective, and comprehensive treatment plans for children with these conditions.

Expanded Treatment Options

A major research challenge pertaining to the treatment of ADHD is the development and evaluation of new treatments for this condition. The 2 current treatments (stimulant medication and behavior therapy) reduce the symptoms and functional consequences of ADHD, but only for as long as they are administered. Treatments with more lasting or even curative effects are needed. A significant number of children do not respond to stimulant medications or have severe side effects. Some families cannot implement behavioral programs. Expanding the available medical and behavioral treatment regimens with additional safe and effective options would be useful for such a prevalent chronic condition where not all children respond to current treatments or adhere to them. Studying common-sense approaches, such as decreasing environmental distraction, should be done. There is also the need for well-designed rigorous studies of currently promoted but less well-established therapies such as occupational therapy, biofeedback, herbs, vitamins, and food supplements. These interventions are not supported by evidence-based studies at the present time.

Long-term Outcomes

Most studies about ADHD and its treatment have been short-term. The long-term outcome of children with ADHD with or without coexisting conditions has not been well studied. Furthermore, there is minimal information about the role of stimulant medication and/or behavior therapy in the natural history of the disorder. Future research should correct these deficits. For this chronic condition, efficacy and safety studies must be extended from weeks or months to years. Long-term outcome studies must be prospective in design and consider changes over time in core symptoms of ADHD, coexisting conditions, and functional outcomes such as occupational successes and long-term relationships.

Service Delivery

Another major research area should address the optimal services and procedures for successful management of ADHD in the real world (ie, in clinical practice and classrooms). Much of the popular controversy over the inappropriate use of stimulant medication relates to how clinicians actually prescribe them. Future research needs to study how medications are actually prescribed and what factors affect physician practice patterns. Research that includes monitoring the outcomes of training will lead to the ability to develop better methods to assist clinicians in using effective treatment practices. Specifically, basic information such as who are the most appropriate clinicians to manage ADHD; the best schedule for follow-up; and the most valid, reliable, sensitive, and cost-effective ways to monitor treatment is essential. Such research must go beyond physician self-reporting and into scrutinizing and evaluating actual practices in clinics and offices. The most effective and efficient methods for affecting change in clinician practices need to be determined. This determination must be broad, taking into account clinician, practice, family, community, and policy issues that affect treatment. Research also should evaluate the role of school- and community-based professionals, as well as primary care clinicians, in delivering treatment services. Little is known about how short- or long-term effectiveness varies as a function of the school and community-based professional involvement. Further, the studies of service delivery need to include a public health and service system approach. They should consider child and family outcomes and cost-effectiveness of care. Linking outcomes to service parameters is an important step in encouraging practice or system change.

Epidemiology and Etiology

The great growth in the diagnosis of ADHD has led to major new work in the study of treatments. As indicated previously, these efforts should continue and expand. Less investigation has addressed the etiology of ADHD (ie, its biological and socioenvironmental causes) and the opportunities arising from that understanding for prevention. For example, would different social and behavioral arrangements in young families affect the onset of ADHD symptoms? Would early intervention in some way decrease rates of ADHD? A clear need exists for active work in understanding the etiology and prevention of ADHD.

CONCLUSION

This clinical practice guideline offers recommendations for the treatment of school-aged children with ADHD in primary care practice. The guideline emphasizes 1) consideration of ADHD as a chronic condition; 2) explicit negotiations about target symptoms; 3) use of stimulant medication and behavior therapy; and 4) close monitoring of treatment outcomes and failures. The guideline further provides suggestions for pediatric office-based management of ADHD. It should help primary care clinicians in their treatment of a common child health problem.

*The effect size for classroom and social behavior in the CCOHTA meta-analysis averaged 0.81; for core symptoms, 0.78; and for intelligence and achievement, 0.34. The first two of these would be considered a large change, the third, a minor to moderate change.³⁴

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Reviewed: 02/2006