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New Evaluation and Treatment Guidelines From an Expert Panel
The Journal of Attention Disorders recently published a special issue in which the results of a large-scale survey conducted with ADHD experts from medical and psychology backgrounds were reported. The goal of this survey was to establish guidelines that address important clinical issues for which there may currently be little controlled scientific evidence, but for which there exists considerable experience in clinical practice. By obtaining and summarizing the opinions of a large number of experts (i.e. 44 physicians and 47 psychologists, representing 86% and 94% of the individuals to whom a survey was sent), the results create a set of guidelines that can be informative to both parents and practitioners.
As noted above, the survey was designed to obtain and synthesize expert opinion on issues that are not yet fully addressed in the research literature on ADHD. The designers of the survey were themselves recognized ADHD experts (Keith Conners is the lead author) and are careful to note that because individuals with ADHD can vary so widely along multiple dimensions, the consensus recommendations will certainly not be appropriate in all circumstances. They are also careful to note that the survey was financially sponsored by the pharmaceutical industry, and describe the steps taken to avoid having this bias the results. The major effort here was to present data from every respondent so that readers can compare the summary guidelines with the raw data on which each guideline is based.
It is also noted appropriately that the guidelines represent current expert opinion, and that expert opinion at any given time can be revealed by future studies to be wrong. For example, future studies may indicate that treatments currently regarded as "alternative", and thus not generally recommended, are actually quite helpful in many cases and should be considered to be important treatment options. The important point here is that any set of recommendations can only be based on the best available evidence, and should this evidence change over time, so will the recommendations.
Survey results were summarized to produce guidelines in multiple areas, including the assessment and treatment of ADHD, how these vary depending on the type of ADHD (i.e. combined, inattentive, or hyperactive-impulsive), and the age of the client. Particular attention is given to important clinical issues such as what to do when treatment is only partially effective or even ineffective, what constitutes adequate monitoring, and how the current state of treatment for ADHD can be improved. Reviewing the entire set of guidelines is beyond the scope of what can be presented here, and the focus in this issue will be on three particular points -- selecting an initial treatment strategy, changing the treatment regimen when response is judged to be inadequate, and what constitutes appropriate ongoing care. In future issues of Attention Research Update, additional guidelines from this report may be presented.
Selecting An Initial Treatment Strategy
The question facing the experts here was how to sequence the treatments for ADHD -- whether to begin with medication alone, psychosocial treatment alone, or a combination of both from the start. Experts were told to assume that both types of treatment would be available, and to rank order their recommendations in terms from most to least preferred option. It is reasonable to assume that by psychosocial treatment, the experts were referring to the types of non-medical interventions for ADHD for which empirical support has been shown, including parent training, clinical behavior therapy, skills-based training, psycho-educational interventions, etc.
Psychosocial Treatment Alone
Starting with psychosocial treatments alone was the consensus recommendation in situations where ADHD symptoms were judged to be mild and/or when the child was of preschool age. In cases where there was a co-occurring internalizing problem (i.e. mood or anxiety disorder), beginning with a psychosocial intervention alone and beginning with a combination of medication and psychosocial treatment were rated equivalently.
Medication Treatment Alone
Beginning with medication treatment alone was never the clearly preferred option among this expert group. It was regarded as equally appropriate to beginning with combined treatments, however, for more severe cases of ADHD, for individuals with the combined or hyperactive-impulsive subtypes, and for adults.
Combined Treatments
Situations where combined treatment was viewed as an equally appropriate initial treatment strategy to medication or psychosocial intervention alone are described above. In addition, combined treatment was regarded as the best initial option for individuals with the predominantly inattentive subtype of ADHD, for children and adolescents, and/or when there are co-occurring behavior disorders (i.e. Oppositional Defiant Disorder or Conduct Disorder).
The consensus opinion of these experts thus shows a strong preference for combined treatment. For children and adolescents, this would be the preferred option except in cases where symptoms were judged to be mild (i.e. psychosocial treatment alone would be reasonable here), or when there is a strong preference for one treatment approach vs. the other. The preference for combined treatment is consistent with MTA study results in which the researchers found a modest, but statistically significant, advantage for combined treatments over medication alone for several specific outcomes and for an overall composite of the different outcomes considered.
Changing The Treatment Regimen
An issue closely related to the choice of initial treatment strategy is the appropriate time to change treatment regimens when the response has been inadequate. Several factors were deemed important to evaluate before making any such change. Before making changes to medication treatment, the following steps were advised:
In regards to switching medications when a positive response to the initial medication choice is not obtained, the panel strongly recommended that several different stimulants be given a thorough trial before trying a different class of medication (e.g. switching to an anti-depressant). Adding new meds rather than trying another type of stimulant first was also not a preferred option.
In cases where medication alone has been used to begin treatment, the consensus was that psychosocial treatment should be added when no response has been noted over a 5-week period of careful trials. In situations where only a partial response (i.e. some symptoms clearly remain and impair functioning), it was recommended that psychosocial interventions be added after 7 weeks. When psychosocial treatment alone has been the initial strategy, the experts advised adding medication when a month has elapsed with no response, and waiting between 6-7 weeks when at least a partial response has been obtained.
What Is An Appropriate Level Of Maintenance Care?
One of the real drawbacks in the care that many children with ADHD receive is the lack of adequate monitoring and follow-up. In addition, those receiving medication often stop taking it prematurely. The guidelines in this section are thus especially important to note.
For children/adolescents who respond well to medication, it is suggested that medication be maintained on the dosage determined to be most effective for 1-2 years before trying to taper it. A typical duration of medication treatment for good responders ranged from 2-10 years. For adults, it was recommended that those showing an excellent medication response continue to take it for 2-5 years before trying to taper or discontinue.
For individuals who have had an excellent response to medication treatment (i.e. symptoms have been fully normalized with no residual impairment), it was advised that follow-up visits be scheduled every 3 months. In cases where only partial response has been obtained, the consensus opinion called for monthly visits. Thus, ongoing monitoring of treatment response is seen as essential.
For psychosocial interventions, weekly visits are recommended during the first 6 months of treatment. A range of 7-20 visits would be held during this period depending on response. This figure is for an "uncomplicated ADHD patient", and would need to be increased when difficulties were more pronounced than is typical.
6-12 months after treatment has been initiated, booster sessions were recommended to be held every 1-3 months once symptoms have been fully normalized, and 1-2 times each month when there has been only a partial response. Sessions for ongoing monitoring beyond 12 months should take place 1 to 2 times per year for children and adolescents, and as needed for adults.
Summary
The recommendations above are important in that they reflect the most widely held views among a large number of experts. As noted above, these guidelines will not apply to every individual, and treatment decisions for specific individuals can be influenced by a wide variety of factors that no set of guidelines can fully capture. In cases where treatment choices fall clearly outside of these guidelines, however, it would be important to be able to specify the factors that have resulted in what would be considered atypical recommendations.
Note: This article originally appeared in Attention Research Update, an online newsletter written by Dr. David Rabiner, a Duke University psychologist and former member of CHADD's Professional Advisory Board. You can learn more about Attention Research Update and sign up for a free subscription at www.helpforadd.com.