International consensus statement on attention-deficit/hyperactivity disorder (ADHD) and disruptive behaviour disorders (DBDs): Clinical implications and treatment practice suggestions
Section snippets
Introduction to the disorders
Attention-deficit/hyperactivity disorder (ADHD) and disruptive behaviour disorders (DBDs) are classified somewhat differently internationally due to the use of two different classification systems—the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSMIV; (American Psychiatric Association, 1994)) and the International Classification of Diseases, 10th Edition (ICD10; (World Health Organisation, 1993)).
DSMIV ADHD is one of the most commonly diagnosed childhood psychiatric
Rationale
Among researchers and clinicians around the world, there are concerns that youngsters with ADHD/DBDs are not receiving the appropriate treatment that they need. Considerable research data indicate a biological basis to these disorders (see below), and compelling evidence has demonstrated their association with poor long-term outcomes in untreated cases. Effective treatments are available, and yet many such youngsters do not receive adequate treatment. Reasons for this are multiple, but a
Key message: do not be satisfied with a single diagnosis; keep assessing to uncover likely comorbidities; accurate diagnosis is essential to improve the prognosis
Accurate differential diagnostic assessment is a pre-requisite to providing effective treatment. Ideally this process should be conducted by a paediatric mental health specialist, but standard practices and lack of availability of such specialists in some countries may dictate otherwise. The consensus of the attendees was that a clinical interview applying established diagnostic criteria (DSMIV or ICD10) is essential to the diagnosis of ADHD/DBDs. Multiple domains (school, home, the community)
Key message: comorbidity is the norm rather than the exception
Attendees acknowledged that comorbidity is the norm rather than the exception for youngsters with ADHD/DBDs. About 50% of youngsters with ADHD are comorbid for ODD and/or CD (Wolraich et al., 1996, Angold et al., 1999); the percentage with comorbid CD tends to increase with age (Szatmari et al., 1989). From the reverse perspective, almost all children under 12 years of age who have CD or ODD also meet the criteria for ADHD (Reeves et al., 1987). In adolescent samples, while cases of pure CD are
Diagnostic tools
In order to establish a categorical diagnosis (in which it is assumed that an extreme symptom is present in cases to an extent that is not seen in most individuals), fully structured interviews such as the Diagnostic Interview Schedule for Children (DISC; (Shaffer et al., 2000)) or the Diagnostic Interview for Children and Adolescents (DICA; (Reich, 2000)) can be used. Other alternatives are the semi-structured Schedule for Affective Disorders and Schizophrenia for School-age Children (K-SADS; (
Heritability
There is a considerable amount of evidence from family pedigree, twin, adoption and molecular genetic studies of the heritability of ADHD. Estimates of heritability range as high as 80–90% (Gilger et al., 1992). There is also significant evidence that non-genetic factors are important in determining the phenotype and that these non-genetic factors interact with the genotype in producing the observed phenotype.
In studies of school age youngsters, CD appears also to have a genetic component
Key message: early identification and intervention in cases of childhood ADHD may preclude the development of CD and minimise the developmental risk conferred by ADHD
Among children with ADHD, the presence of comorbid CD predicts poorer social adjustment in later development (August et al., 1983, Barkley, 1990). This might suggest that CD accounts for all the developmental risk in children with ADHD. However, among children with CD, the presence and severity of hyperactivity also predicts higher levels of antisocial outcome in adolescence (Schachar et al., 1981, Farrington et al., 1990). Also, while childhood ADHD (in the absence of CD as well as in its
Key message: identification of target symptoms at the start of treatment and careful monitoring of response is essential to effective treatment assessment
The attendees acknowledged that certain treatments were highly effective at bringing about improvement in some symptoms of a disorder. For example, parent training may be effective for dealing with the oppositional aspects of CD, while being less effective at treating the aggressive-impulsive components of the disorder. Furthermore, it was recognised that certain medications were effective treatments for particular symptoms across a range of different disorders. For example, the atypical
Key message: psychostimulant medication is the first-line pharmacological treatment in cases of pure ADHD
In terms of the number of controlled studies showing the efficacy of psychopharmacologic treatment for ADHD, psychostimulants outrank all other classes of medication (Spencer et al., 1996). Within this class, although more controlled studies have been published on MPH than on amphetamine, within-subject comparison studies have not found significant differences in either the safety or the efficacy of these two psychostimulants (Arnold, 2000). Pemoline is no longer recommended due to its
Key message: use of long-acting preparations is preferable to multiple doses of short-acting preparations
A number of different long-acting, slow-release preparations of psychostimulant medication are becoming available in many countries. Most of these provide a dose of psychostimulant that lasts for 8 h or more, such as: Adderall XR, Concerta, Metadate CD and Ritalin LA. A significant benefit of these preparations is that the need for a midday dose in school is removed. This is desirable because many youngsters feel stigmatised by having to take medication in front of their peers, and also because
Key message: the atypical neuroleptic, risperidone, may be the medication of choice in treating the symptoms of CD
MPH has been shown to be statistically significantly better than placebo in treating aggression, conduct problems and symptoms of ADHD in outpatient youngsters with CD, two-thirds of whom also met criteria for ADHD. Furthermore the improvement in aggression was found to be unrelated to baseline measures of overall activity level. However, the behaviour of very few of the subjects was normalised (Klein et al., 1997). Aggression has not often been the target of treatment in psychostimulant
Key message: non-pharmacologic interventions that include behavioural modification have been shown to have short-term efficacy as a means of treating ADHD/DBDs, but the effects are location-specific and usually less pronounced than those obtained with psychostimulant medication
A wide variety of non-pharmacologic interventions are used in the treatment of ADHD, ODD and CD worldwide. Of these, only those that include behavioural modification have been shown to be effective. The most commonly implemented form of behavior therapy for these disorders is behavioural parent training (Kazdin, 1997a, Kazdin, 1997b, Kazdin, 2000). Major components of parent-training programs include: contingency management; increasing parents’ ability to monitor and respond appropriately to
Key message: optimal treatment for ADHD and/or CD should combine pharmacotherapy, which addresses core biological symptoms, with psychosocial intervention, which focuses on youngsters’ and families’ attitudes and life strategies
The consensus of the attendees was that psychosocial intervention was a very important component of treatment for ADHD and/or CD. Pharmacotherapy is primarily needed to manage the core biological symptoms of these disorders (inattention, hyperactivity, impulsivity and affective aggression). The role of psychosocial intervention is to bring about changes in the youngster’s and family’s attitudes and life strategies (e.g. addressing the youngster’s self-concept, interpersonal problem-solving
Consensus treatment option suggestions
As stated earlier, these suggestions are intended for use once thorough differential diagnostic assessment has been completed. If mental disorders other than ADHD, CD and ODD are present, the suggestions presented in this document are not applicable; such cases should be considered for specialist referral.
Fig. 1 shows the consensus treatment option pathways suggested for cases of ADHD (which is taken to encompass hyperkinetic disorder) without co-morbid CD; cases of ADHD with co-morbid ODD in
Key messages: (1) the benefits of treatment need to be more effectively conveyed to the youngsters themselves. (2) Mental health problems within the families of youngsters with ADHD/DBDs may need to be addressed directly to ensure that effective treatment can be provided for the youngsters
There is considerable reticence in the minds of the public and some physicians towards the idea of applying psychiatric ‘labels’ to children. There is also considerable disagreement about the idea of treating such children with medication. However, in contradiction to some popular and even professional opinion, effective pharmacologic treatment for ADHD/DBDs exists, and withholding it for ‘philosophical’ reasons is to deny patients and their families, symptom relief and therapeutic gain. There
Summary of key consensus points
In summary, the attendees’ major conclusions and suggestions are as follows:
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ADHD and DBDs are prevalent and chronic conditions associated with poor outcome throughout childhood as well as adulthood in untreated cases. In the majority of cases, negative outcomes associated with lack of treatment far outweigh the risks associated with treatment.
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Comorbidity among ADHD and DBDs is high and should be considered the norm: up to 50% of all ADHD cases are comorbid for ODD/CD; the majority of cases of
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