ADD Resource Center » Research

Caring for Children with ADHD: A Resource Toolkit for Clinicians

Harold Meyer — Thu, 22 Dec 2011 12:11:04 +0000

ADHD – NICHQ Toolkit

National Initiative for Children’s Healthcare Quality

To download the entire toolkit as a zip file, click here.

To download individual documents from the Toolkit, use the links below.

ADHD Assessment Tools

Harold Meyer — Thu, 22 Dec 2011 11:50:55 +0000

These ADHD assessment tools be used for educational purposes only. They are not substitutes for informed psychological advice or training. Do not use this information to diagnose or treat a mental health problem without consulting a qualified health or mental health care provider.

DSM-IV-TR: Attention-Deficit/Hyperactivity Disorder (ADHD) (from Diagnostic and Statistical Manual of Mental Disorders: Fourth Edition Text Revision (DSM-IV-TR))

ICD-10: F90 Hyperkinetic Disorders (from The International Statistical Classification of Diseases and Related Health Problems, tenth revision)

National Initiative for Children’s Healthcare Quality (NICHQ): includes a variety of ADHD- related tools such as rating scales, successful protocols, order sets and forms, and guidelines for implementing key changes. Downloading tools such as the Vanderbilt Assessment Scale for ADHD requires free registration.

ADHD Rating Scale IV — Home Version

ADHD Rating Scale IV — School Version

Child Attention Profile (CAP)

Home Situations Questionnaire [PDF]

School Situations Questionnaire [PDF]

Parents’ Rating Scale for the Attention Deficit Hyperactivity Disorder (requires free registration)

Werry-Weiss-Peters Activity Rating Scale [PDF]

McCann BS, Scheele L, Ward N, Roy-Byrne P.
Discriminant validity of the Wender Utah Rating Scale for attention-deficit/hyperactivity disorder in adults.
J Neuropsychiatry Clin Neurosci. 2000 Spring;12(2):240-5. [Full Text PDF]

Wender Utah Rating Scale (for adults) [DOC]

Adult ADHD/ADD Quiz

The SNAP-IV Teacher and Parent Rating Scale
[Instructions for above]

Adult ADHD Self-Report Scale (ASRS-v1.1) Screener [PDF]

Adult ADHD Self-Report Scale (ASRS-v1.1) [PDF]

Childhood ADHD Symptoms Scale Self-Report [PDF]

Attention-Deficit Scales for Adults (ADSA) [must be purchased]

Conners’ Continuous Performance Test II for Windows (CPT II V.5) [must be purchased]

Gordon Diagnostic System (GDS) [must be purchased]

Test of Everyday Attention for Children (TEA-Ch) [must be purchased]

Test of Variables of Attention (TOVA) [must be purchased]

Conners’ Rating Scales–Revised (CRS–R) [must be purchased]

Brown Attention-Deficit Disorder Scales [must be purchased]

Brown Attention-Deficit Disorder Scales for Children [must be purchased]

Attention-Deficit/Hyperactivity Disorder Test (ADHDT) [must be purchased]

ADHD Symptom Checklist-4 (ADHD-SC4) [must be purchased]

Spadafore ADHD Rating Scale (S-ADHD-RS) [must be purchased]

ADHD Symptoms Rating Scale (ADHD-SRS) [must be purchased]

Copeland Symptom Checklist for Attention Deficit Disorders – Child and Adolescent Version
[must be purchased]

Copeland Symptom Checklist for Attention Deficit Disorders – Adult Version [must be purchased]

CARE – College ADHD Response Evaluation [must be purchased]

ADD-H: Comprehensive Teacher’s Rating Scale: Parent Form (ACTeRS) [must be purchased]

ADD-H: Comprehensive Teacher’s Rating Scale-2nd Edition (ACTeRS) [must be purchased]

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Go to: The ADD Resource Center Home Page.

ADHD medications show no association with heart events

Harold Meyer — Mon, 21 Nov 2011 15:55:26 +0000

This update is in follow-up to the FDA Communication about an Ongoing Safety Review of Stimulant Medications used in Children with Attention-Deficit/Hyperactivity Disorder (ADHD)

Safety Announcement
Additional Information for Patients
Additional Information for Healthcare Professionals
Data Summary

Safety Announcement

[11-01-2011] The U.S. Food and Drug Administration (FDA) is updating the public that a large, recently-completed study in children and young adults treated with medication for Attention-Deficit/Hyperactivity Disorder (ADHD) has not shown an association between use of certain ADHD medications and adverse cardiovascular events. These adverse cardiovascular events include stroke, heart attack (myocardial infarction or MI), and sudden cardiac death.

ADHD medications involved in this safety review

Stimulants

methylphenidate (Concerta, Daytrana, Metadate CD, Metadate ER, Methylin, Methylin ER, Ritalin, Ritalin-LA, Ritalin-SR)
dexmethylphenidate HCl (Focalin, Focalin XR)
dextroamphetamine sulfate (Dexedrine, Dexedrine Spansules, Dextroamphetamine ER, Dextrostat)
lisdexamfetamine dimesylate (Vyvanse)
amphetamine, mixed salts (Adderall, Adderall XR)
methamphetamine (Desoxyn)

Non-stimulants

pemoline (Cylert-no longer marketed)
atomoxetime (Strattera)

The medications studied include stimulants (amphetamine products and methylphenidate), atomoxetine, and pemoline (no longer marketed).

This study did not find an association between use of ADHD medications and cardiovascular events. FDA continues to recommend that healthcare professionals prescribe these medications according to the professional prescribing label.

Healthcare professionals should take special note that:

Stimulant products and atomoxetine should generally not be used in patients with serious heart problems, or for whom an increase in blood pressure or heart rate would be problematic.
Patients treated with ADHD medications should be periodically monitored for changes in heart rate or blood pressure.

Patients should continue to use their medicine for the treatment of ADHD as prescribed by their healthcare professional.

This cohort study, conducted with 1,200,438 children and young adults (aged 2-24 years) and 2,579,104 person-years of follow-up, including 373,667 person-years of current use of ADHD drugs, only found 7 serious cardiovascular events in current users. Person-years is the total sum of the years that each person in a study has been under observation (for a description of the study analysis see the study report or article [link]). Study findings reported no evidence of increased risk of serious cardiovascular effects among children and young people who use ADHD medications. The possibility of a small to modest increase in risk cannot be ruled out because of the small number of serious cardiovascular events observed in the patients studied. (see Data Summary)

This is the first of three separate but related studies that were sponsored by the FDA and the Agency for Healthcare Research and Quality (AHRQ). These studies were designed to evaluate the potential increased risk of heart attack, stroke or sudden cardiac death that could be associated with the use of ADHD medications. FDA will communicate the results of the other two studies (performed in adults) when our review of the study results is complete.

The final study report is being released today: Final Report: Attention Deficit Hyperactivity Disorder Medications and Risk of Serious Cardiovascular Disease in Children and Youth. FDA is also releasing the Statistical Review of the Final Report for Observational Study: Attention Deficit Hyperactivity Disorder Medications and Risk of Serious Cardiovascular Disease in Children and Youth.

This study was published in the New England Journal of Medicine on November 1, 2011 and can be viewed here .¹

With this communication, FDA is providing the Agency’s analysis of the most up-to-date information that is currently available to healthcare professionals and families.

Additional Information for Patients or Caregivers

Continue your ADHD treatment as prescribed by a healthcare professional.
Talk to your healthcare professional about any questions you may have about ADHD medications.
Immediately see a healthcare professional if you or the person you are caring for develops chest pain, shortness of breath, or fainting while taking medication to treat ADHD.
Report any suspected side effects of ADHD medication use to your healthcare professional or to the FDA MedWatch program using the information in the “Contact Us” box at the bottom of the page.

Additional Information for Healthcare Professionals

A large retrospective cohort study in children and young adults (aged 2-24 years) did not show an association between use of ADHD drugs and cardiovascular events, which include MI, stroke or sudden cardiac death. These study results were not consistent with the increase in sudden death estimated in a previous study, however a small to modest increase in risk cannot be excluded.²
Continue to prescribe drugs used for the treatment of ADHD according to the professional prescribing directions.
Report adverse events involving ADHD medications to the FDA MedWatch program, using the information in the “Contact Us” box at the bottom of the page.

Data Summary

A study by Gould et al. suggesting a higher risk of sudden death in children taking stimulant medications for ADHD was discussed in a previous FDA communication.²

Blood pressure and heart rate increases have been observed in patients treated with the sympathomimetics methylphenidate and amphetamine, and with atomoxetine. In view of these effects, plus spontaneous postmarketing reports of serious cardiovascular events with use of ADHD drugs, FDA (in partnership with AHRQ) sponsored observational studies of serious cardiovascular events with drugs for ADHD. The project was divided into three separate but related studies. One study assessed myocardial infarction (MI), stroke, and sudden cardiac death (SCD) with use of ADHD drugs by children and young adults aged 2-24 years. A second study assessed MI and SCD among non-elderly adult users (aged 25-64 years). A third study evaluated stroke in non-elderly adult users, which also included an analysis of the composite endpoint (SCD plus MI plus stroke) in adults.

Each study was a retrospective cohort study using health care claims databases from several sources: Kaiser Permanente, Tennessee Medicaid, Washington State Medicaid, Ingenix, and HMO Research Network. Drug exposures were identified from prescription claims data. Outcomes of stroke, MI, or SCD were identified from diagnoses in claims data, and from searches of vital statistics and death certificate data. Potential cases were either adjudicated from medical records by experts blind to exposure status, or were identified using electronic data case definition algorithms.

This first study, conducted with 1,200,438 children and young adults (aged 2-24 years) and 2,579,104 person-years of follow-up, including 373,667 person-years of current use of ADHD drugs, only found 7 serious cardiovascular events (4 strokes and 3 sudden cardiac deaths) in current ADHD drug users. All 7 events occurred in Medicaid patients, although Medicaid patients contributed only about half of the total exposed person time.

In comparison to non use, there was no association of serious cardiovascular events with ADHD drug use (adjusted hazard ratio 0.75, 95% confidence limits 0.31-1.85). Additional analyses including use of a former user reference group did not materially affect the finding of no association with drug exposure. The inferential value of not finding an association is tempered by the fact that there were only seven serious cardiovascular events during ADHD drug exposure (rate of 1.87 events per 100,000 person-years), suggesting a low absolute risk. This also limited the ability to make statistical comparisons to rates in patients not using ADHD drugs. The results were not consistent with the 7-fold increase in sudden death reported in a case-control study published by Gould et al.,² but a small to modest increase in risk cannot be excluded.

FDA will communicate the results of the other two studies (performed in adults) when our review of the results is complete.

References

Cooper WO, Habel LA, Sox CM, et al. ADHD drugs and serious cardiovascular events in children and young adults. N Engl J Med 2011. ePub ahead of print.http://www.nejm.org/doi/full/10.1056/NEJMoa1110212. Accessed November 1, 2011.
Gould MS, Walsh BT, Munfakh JL, Kleinman M, Duan N, Olfson M, Greenhill L, Cooper T: Sudden death and use of stimulant medications in youth. Am J Psychiatry (published online June 15, 2009; doi:10.1176/appi.ajp.2009.09 040538)

Related Information

ADHD Statistics

kerch — Fri, 23 Sep 2011 15:30:33 +0000

NCHS Data Brief

Number 70, August 2011

Attention Deficit Hyperactivity Disorder Among Children Aged 5–17 Years in the United States, 1998–2009

Key findings

Data from the National Health Interview Survey, 1998–2009

The percentage of children ever diagnosed with attention deficit hyperactivity disorder (ADHD) increased from 7% to 9% from 1998–2000 through 2007–2009.
ADHD prevalence trends varied by race and ethnicity. Differences between groups narrowed from 1998 through 2009; however, Mexican children had consistently lower ADHD prevalence than other racial or ethnic groups.
From 1998 through 2009, ADHD prevalence increased to 10% for children with family income less than 100% of the poverty level and to 11% for those with family income between 100% and 199% of the poverty level.
From 1998 through 2009, ADHD prevalence rose to 10% in the Midwest and South regions of the United States.

Attention deficit hyperactivity disorder (ADHD) is one of the most common mental health disorders of childhood (1). The symptoms of ADHD (inattention, impulsive behavior, and hyperactivity) begin in childhood and often persist into adulthood. These symptoms frequently lead to functional impairment in academic, family, and social settings (2,3). The causes and risk factors for ADHD are unknown, but genetic factors likely play a role (4). Diagnosis of ADHD involves several steps, including a medical exam; a checklist for rating ADHD symptoms based on reports from parents, teachers, and sometimes the child; and an evaluation for coexisting conditions (5). Recent national surveys have documented an increase in the prevalence of ADHD during the past decade (6,7). This report presents recent trends in prevalence and differences between population subgroups of children aged 5–17 years.

Keywords: race, ethnicity, poverty status, National Health Interview Survey

The percentage of children ever diagnosed with ADHD increased from 1998 through 2009 among both boys and girls.

For the 2007–2009 period, an annual average of 9.0% of children aged 5–17 years had ever been diagnosed with ADHD—an increase from 6.9% in 1998–2000 (Figure 1).
From 1998 through 2009, ADHD prevalence was higher among boys than girls: For boys, ADHD prevalence increased from 9.9% in 1998–2000 to 12.3% in 2007–2009, and for girls, from 3.6% to 5.5% during the same period.

NOTE: Access data table for Figure 1 [PDF 87 KB].
SOURCES: CDC/NCHS, Health Data Interactive and National Health Interview Survey.

ADHD prevalence varied by race and ethnicity, but differences between most groups narrowed from 1998 through 2009.

ADHD prevalence increased from 1998–2000 to 2007–2009 for non-Hispanic white children (from 8.2% to 10.6%) and for non-Hispanic black children (from 5.1% to 9.5%) (Figure 2).
In 1998–2000, non-Hispanic white children had higher ADHD prevalence compared with all other race groups, and Mexican children had the lowest prevalence.
In 2007–2009, ADHD prevalence was similar among non-Hispanic white, non-Hispanic black, and Puerto Rican children. ADHD was lower among Mexican children compared with children in the three other racial and ethnic groups.

NOTE: Access data table for Figure 2 [PDF - 87 KB].
SOURCES: CDC/NCHS, Health Data Interactive and National Health Interview Survey.

From 1998 through 2009, ADHD prevalence increased for children with family income less than 100% of the poverty level and for those with family income between 100% and 199% of the poverty level.

From 1998–2000 to 2007–2009, ADHD prevalence increased from 7.5% to 10.3% for children with family income less than 100% of the poverty level, and from 7% to 10.6% for children with family income between 100% and 199% of the poverty level (Figure 3).
In 1998–2000, ADHD prevalence was similar among all income groups, but in 2007–2009 the prevalence was higher among children with family income less than 100% or between 100% and 199% of the poverty level, compared with those with income greater than or equal to 200% of the poverty level.

NOTE: Access data table for Figure 3 [PDF - 87 KB].
SOURCES: CDC/NCHS, Health Data Interactive and National Health Interview Survey.

ADHD prevalence rose in the Midwest and South regions of the United States from 1998 through 2009.

ADHD prevalence rose from 1998–2000 to 2007–2009 in the Midwest region (from 7.1% to 10.2%) and in the South region (from 8.1% to 10.3%) (Figure 4).
In 1998–2000, ADHD prevalence was higher in the South region than in all other regions. In 2007–2009, ADHD prevalence was similar in the South and Midwest regions; prevalence in these two regions was higher than in the Northeast and West regions.

NOTES: For a listing of states in each of the four U.S. Census regions [PDF - 1 MB]. Access data table for Figure 4 [PDF - 87 KB].
SOURCES: CDC/NCHS, Health Data Interactive and National Health Interview Survey.

Summary

From 1998–2000 through 2007–2009, the prevalence of ADHD increased among children aged 5–17 years, from 6.9% to 9.0%. These increases were seen among both boys and girls, among children in most racial and ethnic groups except Mexican children, and among children with family income less than 200% of the poverty level. By geographic region, ADHD was more prevalent in the South and Midwest regions of the United States than in the Northeast and West regions during 2007–2009. Prevalence estimates in this report are based on parental report of the child ever receiving a diagnosis, and thus may be affected by the accuracy of parental memory (including recall bias), by differential access to health care between groups (diagnostic bias), or by willingness to report an ADHD diagnosis. One study that included clinical assessment of children for ADHD symptoms (8) found that only one-half of children meeting the criteria for ADHD had received a diagnosis of ADHD or regular medication treatment. For the present report, it was not possible to discern whether growing prevalence indicates a true change in prevalence or increased detection and diagnosis of ADHD. Nevertheless, the societal costs of ADHD—including those associated with medical, educational, and criminal justice resources—are large (8).

Definitions

ADHD prevalence: Estimated based on the number of adults responding “yes” to the question, “Has a doctor or health professional ever told you that your child had Attention Deficit Hyperactivity Disorder (ADHD) or Attention Deficit Disorder (ADD)?” This question is included in the standard National Health Interview Survey (NHIS) Sample Child questionnaire.

Poverty status or percentage of poverty level: Based on family income, family size, the number of children in the family, and, for families with two or fewer adults, on the age of the adults in the family. The poverty level is based on a set of income thresholds that vary by family size and composition. Families or individuals with income below their appropriate thresholds are classified as below the poverty level. These thresholds are updated annually by the U.S. Census Bureau to reflect changes in the Consumer Price Index for all urban consumers (9). Estimates by poverty status from NHIS are based on both reported and imputed family income (10).

Data source and methods

All ADHD prevalence estimates were obtained from the Health Data Interactive (HDI) table, “Attention deficit hyperactivity disorder, learning disability, behavior difficulty, ages 5–17: U.S., 1998–2009,” available from the Health Data Interactive website. NHIS data were used to estimate ADHD prevalence for this HDI table.

NHIS data are collected continuously throughout the year for the Centers for Disease Control and Prevention’s (CDC) National Center for Health Statistics (NCHS) by interviewers from the U.S. Census Bureau. NHIS collects information about the health and health care of the civilian noninstitutionalized U.S. population. Interviews are conducted in respondents’ homes, but follow-ups to complete interviews may be conducted over the telephone. The Sample Child component collects detailed data on health conditions for a randomly selected child in households with at least one child. A responsible adult, usually a parent, responds to the survey questions as proxy for the sample child. For further information about NHIS and the questionnaire, visit the NHIS website.

NHIS is designed to yield a sample that is representative of the civilian noninstitutionalized population of the United States, and the survey uses weighting to produce national estimates. Data weighting procedures are described in more detail elsewhere (11). Point estimates and estimates of corresponding variances for the HDI estimates were calculated using SUDAAN software (12) to account for the complex sample design of NHIS. The Taylor series linearization method was chosen for variance estimation.

Differences between percentages were evaluated using two-sided significance tests at the 0.05 level. Terms such as “higher than” and “less than” indicate statistically significant differences. Terms such as “similar” and “no difference” indicate that the statistics being compared were not significantly different. Lack of comment regarding the difference between any two statistics does not necessarily suggest that the difference was tested and found to be not significant.

All estimates shown in this report have a relative standard error less than or equal to 30%. The significance of trends was tested using weighted least squares regression models of the log of each outcome and Joinpoint software (13) to determine whether an apparent change over time was statistically significant, taking into account the standard error for each data point.

About the authors

Lara Akinbami, Xiang Liu, Patricia Pastor, and Cynthia Reuben are with the Centers for Disease Control and Prevention’s National Center for Health Statistics, Office of Analysis and Epidemiology.

References

Fulton BD, Scheffler RM, Hinshaw SP, Levine P, Stone S, Brown TT, Modrek S. National variation of ADHD diagnostic prevalence and medication use: Health care providers and education policies. Psychiatr Serv 60(8):1075–83. 2009.
Barkley RA. Associated cognitive, developmental, and health problems. In: Barkley RA, Murhpy KR, eds. Attention-deficit hyperactivity disorder: A clinical workbook. 3rd ed. New York, NY: Guilford Press 122–83. 2006.
Yoshimasu K, Barbaresi WJ, Colligan RC, Killian JM, Voigt RG, Weaver AL, Katusic SK. Gender, attention-deficit/hyperactivity disorder, and reading disability in a population-based birth cohort. Pediatrics 126(4):e788–95. 2010.
Khan SA, Faraone SV. The genetics of ADHD: A literature review of 2005. Curr Psychiatry Rep 8(5):393–7. 2006.
American Academy of Pediatrics. Clinical practice guideline: Diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. Pediatrics 105(5):1158–70. 2000.
CDC. Increasing prevalence of parent-reported attention-deficit/hyperactivity disorder among children—United States, 2003 and 2007. MMWR 59(44):1439–43. 2010.
Boyle CA, Boulet S, Schieve LA, Cohen RA, Blumberg SJ, Yeargin-Allsopp M, et al. Trends in the prevalence of developmental disabilities in U.S. children, 1997–2008. Pediatrics 127(6):1034–42. 2011.
Pelham WE, Foster EM, Robb JA. The economic impact of attention-deficit/hyperactivity disorder in children and adolescents. J Pediatr Psychol 32(6):711–27. 2007.
U.S. Census Bureau: Poverty 2011.
Schenker N, Raghunathan TE, Chiu P-L, Makuc DM, Zhang G, Cohen AJ. Multiple imputation of family income and personal earnings in the National Health Interview Survey: Methods and examples [PDF 814 KB]. Hyattsville, MD: National Center for Health Statistics. 2008.
Botman SL, Moore TF, Moriarity CL, Parsons VL. Design and estimation for the National Health Interview Survey, 1995–2004 [PDF 300 KB]. National Center for Health Statistics. Vital Health Stat 2(130). 2000.
SUDAAN, release 9.1 [computer software]. Research Triangle Park, NC: RTI International. 2004.
Joinpoint Regression Program, version 3.4 [computer software]. Bethesda, MD: National Cancer Institute, National Institutes of Health. 2010.

Suggested citation

Akinbami LJ, Liu X, Pastor PN, Reuben CA. Attention deficit hyperactivity disorder among children aged 5–17 years in the United States, 1998–2009. NCHS data brief, no 70. Hyattsville, MD: National Center for Health Statistics. 2011.

Copyright information

All material appearing in this report is in the public domain and may be reproduced or copied without permission; citation as to source, however, is appreciated.

National Center for Health Statistics

Edward J. Sondik, Ph.D., Director
Jennifer H. Madans, Ph.D., Associate Director for Science

Office of Analysis and Epidemiology

Linda T. Bilheimer, Ph.D., Director

Prevalence and correlates of adult ADHD in the United States

kerch — Mon, 19 Sep 2011 21:51:47 +0000

The prevalence and correlates of adult ADHD in the United States: Results from the National Comorbidity Survey Replication

Ronald C. Kessler, PhD,¹ Lenard Adler, MD,² Russell Barkley, PhD,³ Joseph Biederman, MD,⁴ C. Keith Conners, PhD,⁵ Olga Demler, MA, MPH,¹ Stephen V. Faraone, Ph.D., Laurence L. Greenhill, MD,⁷ Mary J. Howes, PhD,¹ Kristina Secnik, PhD,⁸ Thomas Spencer, MD,⁴ T. Bedirhan Ustun, MD,⁹ Ellen E. Walters, MS,¹ and Alan M. Zaslavsky, PhD¹

¹Department of Health Care Policy, Harvard Medical School

²Departments of Neurology and Psychiatry, New York University Medical Center

³Department of Psychiatry, Medical University of South Carolina

⁴Department of Psychiatry, Massachusetts General Hospital

⁵Duke University Medical Center

^*Medical Genetics Research Center and Department of Psychiatry, SUNY Upstate Medical University

⁷Division of Child and Adolescent Psychiatry, Columbia University and New York State Psychiatric Institute

⁸Eli Lilly and Company, Global Health Outcomes

⁹Global Burden of Disease Unit, World Health Organization

Address comments to RC Kessler, Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA 02115. Voice: 617-432-3587; Fax: 617-432-3588; Email: kessler@hcp.med.harvard.edu

The publisher’s final edited version of this article is available free at Am J Psychiatry

See commentary in volume 9 on page 116.

See other articles in PMC that cite the published article.

Other Sections▼

Abstract

OBJECTIVE

Despite growing interest in adult attention-deficit/hyperactivity disorder (ADHD), little is known about prevalence or correlates.

METHODS

A screen for adult ADHD was included in a probability sub-sample (n = 3199) of 18–44 year old respondents in the National Comorbidity Survey Replication (NCS-R), a nationally representative household survey that used a lay-administered diagnostic interview to assess a wide range of DSM-IV disorders. Blinded clinical follow-up interviews of adult ADHD were carried out with 154 NCS-R respondents, over-sampling those with a positive screen. Multiple imputation (MI) was used to estimate prevalence and correlates of clinician-assessed adult ADHD.

RESULTS

Estimated prevalence of current adult ADHD is 4.4%. Significant correlates include being male, previously married, unemployed, and Non-Hispanic White. Adult ADHD is highly comorbid with many other NCS-R/DSM-IV disorders and is associated with substantial role impairment. The majority of cases are untreated, although many obtain treatment for other comorbid mental and substance disorders.

CONCLUSIONS

Efforts are needed to increase the detection and treatment of adult ADHD. Research is needed to determine whether effective treatment would reduce the onset, persistence, and severity of disorders that co-occur with adult ADHD.

Keywords: Attention Deficit Hyperactivity Disorder – AJP0005, Diagnosis And Classification – AJP0086, Epidemiology – AJP0087

Other Sections▼

Although it has long been known that attention-deficit/hyperactivity disorder (ADHD) often persists into adulthood (1, 2), adult ADHD has only recently become the focus of widespread clinical attention (3–5). As an indication of this neglect, adult ADHD was not included in either major US psychiatric epidemiological survey of the past two decades, the Epidemiologic Catchment Area Study (6) and the National Comorbidity Survey (7). Attempts to estimate adult ADHD prevalence by extrapolating from childhood prevalence estimates linked with adult persistence estimates (8–11) and direct estimation in small samples (12, 13) yield estimates in the range 1–6%. In order to obtain more accurate estimates of prevalence and correlates, an adult ADHD screen was included in the National Comorbidity Survey Replication (NCS-R) (14) and clinical reappraisal interviews were carried out with screened positives. These data are used here to estimate the prevalence, comorbidity, and impairment of adult ADHD in the US.

Other Sections▼

METHODS

Sample

As detailed elsewhere (15) the NCS-R is a nationally representative survey of 9282 English-speaking household residents ages 18+. The response rate was 70.9%. Recruitment featured an advance letter and Study Fact Brochure followed by in-person interviewer visit to answer questions before obtaining verbal informed consent. Consent was verbal rather than written to parallel the baseline NCS procedures (7) for trend comparison. The Human Subjects Committees of Harvard Medical School and the University of Michigan both approved these procedures.

The NCS-R interview was in two parts. Part I included a diagnostic assessment administered to all 9282 respondents. Part II included additional questions administered to 5692 Part I respondents that included all who met criteria for at least one Part I disorder and a probability sub-sample of others. Based on concern about recall failure among older adults, ADHD was assessed in Part II only among the 3199 respondents aged 18–44. This sample was weighted to be nationally representative. More details about NCS-R weighting are reported elsewhere (15).

Respondents were divided into four strata to select cases for adult ADHD clinical reappraisal interviews: those who denied ever having symptoms of childhood ADHD; those who reported symptoms but did not meet full criteria for childhood ADHD; childhood cases who denied adult symptoms; and childhood cases who reported adult symptoms. An attempt was made to contact by telephone and administer a semi-structured adult ADHD clinical interview to 30 respondents in each of the first three strata and 60 in the fourth. The final quota sample included 154 respondents (slightly more than the target because more pre-designated respondents kept their appointments to be interviewed than expected). These cases were weighted to be representative of the US population in the age range of the sample. Details on the ADHD clinical reappraisal sample design are reported elsewhere (16).

Adult ADHD

The retrospective assessment of childhood ADHD in the NCS-R was based on the Diagnostic Interview Schedule for DSM-IV (17). Respondents classified retrospectively as having had ADHD symptoms in childhood were then asked a single question about whether they continued to have any current problems with attention or hyperactivity-impulsivity. The clinical reappraisal interview used the Adult ADHD Clinical Diagnostic Scale (ACDS) V 1.2 (18, 19), a semi-structured interview that includes the ADHD Rating Scale (ADHD-RS) (20) for childhood ADHD and an adaptation of the ADHD-RS to assess current adult ADHD. The ACDS has been used in clinical trials of adult ADHD (21, 22).

Four experienced clinical interviewers (all Ph.D. clinical psychologists) carried out the clinical reappraisal interviews. Each interviewer received 40 hours of training from two board certified psychiatrist specialists in adult ADHD (LA, TS) and successfully completed five practice interviews. All clinical interviews were tape recorded and reviewed by a supervisor. Weekly calibration meetings were used to prevent drift. A clinical diagnosis of adult ADHD required six symptoms of either inattention or hyperactivity-impulsivity during the six months before the interview (DSM-IV Criterion A), at least two Criterion A symptoms before age seven (Criterion B), some impairment in at least two areas of living during the past six months (Criterion C), and clinically significant impairment in at least one of these areas (Criterion D). No attempt was made to operationalize DSM-IV diagnostic hierarchy rules (Criterion E).

Comorbid DSM-IV disorders

Other DSM-IV disorders were assessed in the NCS-R using the World Health Organization’s (WHO) Composite International Diagnostic Interview (CIDI) Version 3.0 (23), a fully structured lay-administered diagnostic interview. The disorders include anxiety disorders, mood disorders, substance use disorders, and intermittent explosive disorder. Organic exclusion rules and diagnostic hierarchy rules were used in making diagnoses. As detailed elsewhere (15), blinded clinical reappraisal interviews using the Structured Clinical Interview for DSM-IV (SCID) (24) with a probability sub-sample of NCS-R respondents found generally good concordance of DSM-IV diagnoses based on the CIDI and SCID, with AUC .65-.81 for anxiety disorders, .75 for major depression, and .62-.88 for substance disorders. No validation was made of intermittent explosive disorder, as no gold standard clinical assessment exists for this disorder.

Other correlates of adult ADHD

We examined associations of adult ADHD with socio-demographics and functional disability assessed in the WHO Disability Assessment Schedule (WHO-DAS) (25). The WHO-DAS assesses frequency and intensity of difficulties experienced over the past 30 days in each of three areas of basic functioning: mobility (e.g., walking a mile), self-care (e.g., getting dressed) and cognition (e.g., remembering to do important things); and three areas of instrumental functioning: time out of role (i.e., number of days totally unable to carry out normal daily activities; number of days of cutting back on amount done or time spent on daily activities), productive role performance (e.g., cutting back on the quality of work) and social role performance (e.g., controlling emotions when around other people). Dichotomous measures of disability were defined for each domain by giving equal weights to frequency and intensity of impairments and defining the top ten percentile of the composite as being disabled. Treatment was assessed in each diagnostic section and in a separate treatment section where we asked about treatment for any emotional or substance problem. Comparison of responses to the more and less inclusive questions pinpointed people in treatment for comorbid mental or substance problems but not for ADHD.

Analysis methods

The multiple imputation (MI) method (26) was used to assign predicted diagnoses of clinician-assessed adult ADHD to respondents who did not participate in the reappraisal interviews. As detailed below, a strong monotonic relationship was found between sampling strata and blinded adult ADHD clinical diagnoses, justifying this use of MI. We began by selecting ten pseudo-samples of size 154 with replacement from the 154 cases in the clinical calibration sample, estimating predicted probabilities of adult ADHD in each sampling stratum of each pseudo-sample, and transforming probabilities to case classifications separately for each case by random selection from the binomial distribution for the predicted probability. These imputations were then used to create ten separate “datasets” in which substantive analyses were replicated. The parameter estimates in these replications were averaged to obtain MI parameter estimates, while MI parameter variance was estimating by combining the mean within-replication variance with the variance of the parameter estimates across the replications using standard MI averaging (26). The increase in variance due to between-replication variance adjusted for the variance introduced by using imputation rather than direct clinical evaluation of all respondents.

Socio-demographic correlates were estimated using logistic regression analysis, again separately in the ten MI replications. Comorbidity was assessed by obtaining MI estimates of odds-ratios (OR’s) between adult ADHD and other DSM-IV disorders in logistic regression equations that controlled for age in five-year age groups. Functional disabilities were also estimated using MI logistic regression. Twelve-month treatment was estimated using MI cross-tabulations. Because the sample design used weighting and clustering, all parameters were estimated using the Taylor series linearization method (27), a design-based method implemented in the SUDAAN software system (28). Significance tests of set of coefficients used Wald χ² tests based on design-corrected MI coefficient variance-covariance matrices. Statistical significance was evaluated using two-sided design-based .05 level tests.

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RESULTS

Prevalence

85.8% of respondents (Table 1) reported no clinically significant problems with inattention, hyperactivity, or impulsivity during their childhoods. Smaller percentages reported sub-threshold childhood symptoms (7.5%), full childhood criteria without current symptoms (4.0%), and full childhood criteria with current symptoms (2.6%). A strong monotonic relationship was found between this four-category classification and blinded clinical diagnoses of adult ADHD in the reappraisal interviews, with an area under the receiver operator characteristic curve (AUC) in the weighted clinical calibration sample of .86. No false negatives were found among the 85.6% of respondents who reported no childhood symptoms of ADHD, although false negatives were found among respondents who reported sub-threshold symptoms. The estimated prevalence of clinician-assessed adult ADHD (standard error in parentheses) in the total sample based on MI, using a combination of directly interviewed cases from the clinical reappraisal sample and multiply imputed cases in the remainder of the sample, is 4.4% (0.6). It is noteworthy that exactly the same estimated prevalence and standard error are obtained by using a more conventional two-stage sampling adjustment (29).

Table 1

Distribution of Adult ADHD imputation classes in the NCS-R¹ and conditional prevalence of clinician-rated Adult ADHD in the clinical reappraisal sub-sample

Socio-demographic correlates

MI estimates of clinician-assessed adult ADHD are estimated to be significantly elevated among men, Non-Hispanic Whites compared to Non-Hispanic Blacks and Hispanics (i.e., the latter have significantly lower odds than Non-Hispanic Whites), the previously married, and people in the “other” (mostly unemployed and disabled) employment category. (Table 2) The OR’s of these predictors are all modest in substantive terms (1.6–3.3).

Table 2

Socio-demographic correlates of Adult ADHD (n=3199)¹

Comorbidity with other DSM-IV disorders

Adult ADHD is significantly comorbid with a wide range of other 12-month DSM-IV disorders. (Table 3) Strength of comorbidity does not vary greatly across classes of disorder, with OR’s of 2.7–7.5 for mood disorders, 1.5–5.5 for anxiety disorders, 1.5–7.9 for substance disorders, and 3.7 for intermittent explosive disorder.

Table 3

Twelve-month comorbidities of Adult ADHD with other DSM-IV disorders (n=3199)¹

Basic and instrumental functioning

Adult ADHD is associated with significantly elevated OR’s of disability in all three WHO-DAS dimensions of basic functioning — self-care (2.2), mobility (3.9), and cognition (2.6) — as well as all three dimensions of instrumental functioning — days out of role (2.7), productive role functioning (2.1), and social role functioning (3.5).

Twelve-month treatment

A significantly higher proportion of females than males with adult ADHD received treatment for mental or substance problems in the 12 months before interview (53.1% vs. 36.5%, z = 2.6, p = .014). However, only 25.2% of treated cases received treatment for ADHD (22.8% of females vs. 27.7% of males, z = 0.5, p = .598). Because of this low proportion, only 10.9% of respondents with adult ADHD received treatment for ADHD in the 12 months before interview (12.1% of females vs. 10.1% of males, z = 0.4, p = .657).

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DISCUSSION

An important limitation is that the DSM-IV criteria for ADHD were developed with children in mind and offer only limited guidance regarding diagnosis among adulthood. Clinical studies make it clear that symptoms of ADHD are more heterogeneous and subtle in adults than children (32, 33), leading some clinical researchers to suggest that assessment of adult ADHD might require an increase in the variety of symptoms assessed (34), a reduction in the severity threshold (35), or a reduction in the DSM-IV six-of-nine symptom requirement (36). To the extent that such changes would lead to a more valid assessment than in the current study, our prevalence estimate is conservative.

Three additional limitations are also noteworthy. First, adult ADHD was assessed comprehensively only in the clinical reappraisal sub-sample. Although the imputation equation was strong, the need to impute entire diagnoses made it impossible to carry out symptom-level investigations of such things as the notion that inattentive symptoms are more prominent than hyperactive/impulsive symptoms among adults than children.

Second, both the CIDI and clinical reappraisal interviews were based on self-reports. Childhood ADHD is diagnosed based on parent and teacher reports (37). Informant assessment is much more difficult for adults, making it necessary to base assessment largely on self-report (38). Methodological studies comparing adult self-reports versus informant reports of ADHD symptoms document the same general pattern of under-estimation in self-reports in adults as children (39, 40), suggesting that our prevalence estimates is probably conservative, although the only study of self versus informant assessment of adult ADHD in a non-clinical sample found fairly strong associations between the two reports (41).

Third, even though the semi-structured interview used in the clinical reappraisal interviews, the ACDS, had been used in clinical studies of adult ADHD, no standard method of clinical validation of adult ADHD exists with the same level of acceptance as the SCID has for anxiety, mood, or substance disorders, limiting the interpretability of results.

Within the context of these limitations, the results reported document that adult ADHD is a commonly occurring and often seriously impairing disorder. The 4.4 % estimated prevalence is in the middle of previous estimates. This estimate is likely to be conservative for reasons described above. The findings that adult ADHD is associated with unemployment and being previously married are broadly consistent with studies that have documented adverse effects of adult ADHD (8, 42). The WHO-DAS analyses are also consistent with this broad pattern. However, the WHO-DAS might under-represent ADHD impairments because some WHO-DAS dimensions tap areas where ADHD is not highly impairing (e.g., people with ADHD are often very mobile and overwork) and because the WHO-DAS does not assess many dimensions where people with ADHD are thought to function least adequately (e.g., poor sleep and nutrition, high rates of accidents, high smoking). In addition, as noted in the last paragraph, people with ADHD might have poor insight into their impairments, leading to underestimation of WHO-DAS scores.

The finding of low prevalence among Hispanics and Non-Hispanic Blacks was unexpected. As the DSM-IV ADHD field trials found no effects of race-ethnicity (43), the NCS-R result could reflect a race-ethnic difference either in adult persistence, in accuracy of adult self-report, in cultural perceptions of the acceptability of ADHD symptoms, or some combination. The finding that adult ADHD is significantly more prevalent among men than women, in comparison, is consistent with much previous research (44). The 1.6 male:female OR is comparable to the OR’s found in studies of children and adolescents, suggesting that childhood-adolescent ADHD is no more likely to persist into adulthood among girls than boys (45). This indirectly suggests that the high proportion of adult women in adult ADHD patient samples is due to help-seeking or recognition bias (46). The finding that adult ADHD is highly comorbid is consistent with clinical evidence (42). Methodological analysis shows that these comorbidities are not due to overlap of symptoms, imprecision of diagnostic criteria, or other methodological confounds (47).

The average magnitude of OR’s between adult ADHD and other comorbid disorders is comparable to most NCS DSM-IV anxiety and mood disorders (48). The absence of strong variation in comorbidity OR’s was surprising, as family studies would lead us prediction of high comorbidities with major depression (49), bipolar disorder (50, 51), and conduct disorder (52, 53), and lower comorbidities with anxiety disorders (54). One striking implication of the high overall comorbidity is that many people with adult ADHD are in treatment for other mental or substance disorders, but not ADHD. The 10% of cases who receive treatment for adult ADHD is much lower than for anxiety, mood, or substance disorders (55). Direct-to-consumer outreach and physician education are needed to address this problem.

The comorbidity findings raise the question whether early successful treatment of childhood ADHD would influence secondary adult disorders. The fact that a diagnosis of adult ADHD requires at least some symptoms to begin before age 7, means that the vast majority of comorbid conditions are temporally secondary to adult ADHD. We know from the MTA study that successful treatment of childhood ADHD also reduces childhood symptoms of comorbid disorders (56). Indirect evidence suggests that stimulant treatment of childhood ADHD might reduce subsequent risk of substance use disorders (57), although this is not definitive because of possible sample selection bias. Long-term prospective research using quasi-experimental methods is needed to resolve this uncertainty.

A related question is whether adult treatment of ADHD would have any effects on severity or persistence of comorbid disorders. A question could also be raised whether ADHD explains part of the adverse effects found in studies of comorbid DSM disorders. A number of studies, for example, have documented high societal costs of anxiety (58, 59), mood (60, 61), and substance (62, 63) disorder, but these all ignored the role of comorbid ADHD. Reanalysis might find that comorbid ADHD accounts for part, possibly a substantial part, of the effects previously attributed to these other disorders.

ACKNOWLEDGEMENTS

The National Comorbidity Survey Replication (NCS-R) is supported by the National Institute of Mental Health (NIMH; U01-MH60220) with supplemental support from the National Institute of Drug Abuse, the Substance Abuse and Mental Health Services Administration, the Robert Wood Johnson Foundation (Grant # 044780), and the John W. Alden Trust. Additional support for the ADHD screening scale validation re-interviews was provided by an unrestricted educational grant from the Eli Lilly Company. Collaborating NCS-R investigators include Ronald C. Kessler (Principal Investigator, Harvard Medical School), Kathleen Merikangas (Co-Principal Investigator, NIMH), James Anthony (Michigan State University), William Eaton (The Johns Hopkins University), Meyer Glantz (NIDA), Doreen Koretz (Harvard University), Jane McLeod (Indiana University), Mark Olfson (Columbia University College of Physicians and Surgeons), Harold Pincus (University of Pittsburgh), Greg Simon (Group Health Cooperative), Michael Von Korff (Group Health Cooperative), Philip Wang (Harvard Medical School), Kenneth Wells (UCLA), Elaine Wethington (Cornell University), and Hans-Ulrich Wittchen (Max Planck Institute of Psychiatry). The views and opinions expressed in this report are those of the authors and should not be construed to represent the views of any of the sponsoring organizations, agencies, or US Government. A complete list of NCS publications and the full text of all NCS-R instruments can be found at http://www.hcp.med.harvard.edu/ncs. Send correspondence to NCS@hcp.med.harvard.edu. The NCS-R is carried out in conjunction with the World Health Organization World Mental Health (WMH) Survey Initiative. We thank the staff of the WMH Data Collection and Data Analysis Coordination Centres for assistance with instrumentation, fieldwork, and consultation on data analysis. A complete list of WMH publications and instruments can be found at (http://www.hcp.med.harvard.edu/wmhcidi).

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ADHD and Emotional Regulation Video by Dr. Russell A. Barkley

Harold Meyer — Mon, 29 Aug 2011 21:36:34 +0000

Dr Russell Barkley, Ph.D giving a lecture on ADHD at The Centre for ADHD/ADD Advocacy Canada (CADDAC

Dr. Barkley’s website can be found at: http://www.russellbarkley.org/

Books and videos by Dr. Barkley: CLICK HERE

ADHD Data and Statistics in THE USA

Harold Meyer — Sat, 30 Jul 2011 16:51:49 +0000

Data & Statistics

In the United States

The American Psychiatric Association states in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) that 3%-7% of school-aged children have ADHD. 1 However, studies have estimated higher rates in community samples.
Recent data from surveys of parents indicate that:
[Read article]
- Approximately 9.5% or 5.4 million children 4-17 years of age have ever been diagnosed with ADHD, as of 2007.
- The percentage of children with a parent-reported ADHD diagnosis increased by 22% between 2003 and 2007.
- Rates of ADHD diagnosis increased an average of 3% per year from 1997 to 2006 [Read article ] and an average of 5.5% per year from 2003 to 2007.
- Boys (13.2%) were more likely than girls (5.6%) to have ever been diagnosed with ADHD.
- Rates of ADHD diagnosis increased at a greater rate among older teens as compared to younger children.
- The highest rates of parent-reported ADHD diagnosis were noted among children covered by Medicaid and multiracial children.
- Prevalence of parent-reported ADHD diagnosis varied substantially by state, from a low of 5.6% in Nevada to a high of 15.6% in North Carolina.

State-based Prevalence Data of ADHD Diagnosis (2007-2008)

Medication Treatment

[Read article]

As of 2007, 2.7 million youth ages 4-17 years (66.3% of those with a current diagnosis) were receiving medication treatment for the disorder. [Read article]
Rates of medication treatment for ADHD varied by age and sex; children aged 11-17 years of age were more likely than those 4-10 years of age to take medication, and boys are 2.8 times more likely to take medication than girls [Read article]

In 2003, geographic variability in prevalence of medication treatment ranged from a low of 2.1% in California to a high of 6.5% in Arkansas. [Read article]

State-based Prevalence Data of ADHD Medication Treatment (2003)

Diagnosed Attention Deficit Hyperactivity Disorder and Learning Disability: United States, 2004-2006

[Read article ]

About 5% of children had ADHD without Learning Disability (LD), 5% had LD without ADHD, and 4% had both conditions.
Children 12-17 years of age were more likely than children 6-11 years of age to have each of the diagnoses.
Hispanic children were less likely than non-Hispanic white and non-Hispanic black children to have ADHD (with and without LD).
Children with Medicaid were more likely than uninsured children or privately insured children to have each of the diagnoses.
Children with each of the diagnoses were more likely than children with neither ADHD nor LD to have other chronic health conditions.
Children with ADHD (with and without LD) were more likely than children without ADHD to have contact with a mental health professional, use prescription medication, and have frequent health care visits.

Peer Relationships

[Read article]

Parents of children with a history of ADHD report almost 3 times as many peer problems as those without a history of ADHD (21.1% vs. 7.3%).
Parents report that children with a history of ADHD are almost 10 times as likely to have difficulties that interfere with friendships (20.6% vs. 2.0%).

Injury

A higher percentage of parents of children with attention-deficit/hyperactivity disorder reported non-fatal injuries (4.5% vs. 2.5% for healthy children). [Read article]
Children with ADHD, compared to children without ADHD, were more likely to have major injuries (59% vs. 49%), hospital inpatient (26% vs. 18%), hospital outpatient (41% vs. 33%), or emergency department admission (81% vs. 74%). [Read article]
Data from international samples suggest that young people with high levels of attentional difficulties are at greater risk of involvement in a motor vehicle crash, drinking and driving, and traffic violations. [Read article]

Economic Cost

Using a prevalence rate of 5%, the annual societal ‘‘cost of illness’’ for ADHD is estimated to be between $36 and $52 billion, in 2005 dollars. It is estimated to be between $12,005 and $17,458 annually per individual. [Read article]
There were an estimated 7 million ambulatory care visits for ADHD in 2006. [Read article ]
The total excess cost of ADHD in the US in 2000 was $31.6 billion. Of this total, $1.6 billion was for the treatment of patients, $12.1 billion was for all other health care costs of persons with ADHD, $14.2 billion was for all other health care costs of family members with ADHD, and $3.7 billion was for the work loss cost of adults with ADHD and adult family members of persons with ADHD. [Read article]
ADHD creates a significant financial burden regarding the cost of medical care and work loss for patients and family members. The annual average direct cost for each per ADHD patient was $1,574, compared to $541 among matched controls. The annual average payment (direct plus indirect cost) per family member was $2,728 for non-ADHD family members of ADHD patients versus $1,440 for family members of matched controls. [Read article]
Across 10 countries, it was projected that ADHD was associated with 143.8 million lost days of productivity each year. Most of this loss can be attributed to ADHD and not co-occurring conditions. [Read article]
Workers with ADHD were more likely to have at least one sick day in the past month compared to workers without ADHD. [Read article]

Footnotes:

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR. Washington: American Psychiatric Association, 2000.

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High IQ Kids With ADHD – Thomas E. Brown, Ph.D.

Harold Meyer — Tue, 26 Jul 2011 12:49:07 +0000

Bright students are not immune from the cognitive difficulties that plague other children and adolescents with attention deficit disorder, a new Yale study has found.

For the complete report: High-IQ-Kids-with-ADHD

Youth with high IQs and ADHD suffered difficulty with working memory, processing speed, organization and focus, according to the study published online July 26 in the Open Journal of Psychiatry.

“When children and adolescents with high IQ and ADD are struggling with their studies, parents, teachers and physicians tend to blame their difficulties with focus and output on laziness or lack of motivation.,” said Thomas E. Brown, assistant clinical professor of psychiatry, associate director of the Yale Clinic for Attention and Related Disorders and senior author of the study. “They assume that a high IQ student cannot suffer from ADD.”

Researchers identified 117 students ages six to 17 years old with IQ scores within the top 9% of the population. All these students fully met diagnostic criteria for ADD. The study measured IQ, narrative recall and ability to organize and initiate tasks while managing frustration.

Brown found patterns of impairment in all of these measures in this sample of youths with ADD.

For instance, a high IQ child without ADD is likely to have high scores on all four sections of the IQ test, but 75-80% of those with ADD scored high on two sections but significantly lower on working memory and processing speed. In the narrative recall test, most children who do well on the verbal portion of the IQ test do well on recall, high IQ children with ADD did considerably worse.

High IQ children with ADD are rarely diagnosed with ADD until late in their schooling, after the disorder has caused lasting damage to their academics and self-esteem, Brown said.

Brown hopes that this study increases awareness of parents, educators and physicians that ADD can occur in smart children – and that it can be diagnosed and treated.

This study extends findings these same researchers obtained in an earlier published study of 157 high IQ adults with ADD. Similar results were obtained in both age groups.

Development of Preventive Interventions for ADHD (Audio)

kerch — Tue, 05 Apr 2011 10:19:21 +0000

No longer science fiction: The Development of Preventive Interventions for ADHD

(AUDIO ONLY)

Dr. Jeffrey Halperin, Ph.D. will discuss in this audio presentation:

Start with the notion that “Prevention is better than cure” (Desiderius Erasmus, 1466 – 1536) and will consider ways in which preventive interventions can be used to alter the all-too-common adverse course of ADHD over the lifetime.

Reframe current notions about ADHD into a developmental perspective that better reflects the changing nature of the disorder from the preschool years through adulthood.

Describe brain changes over time that parallel the diverse behavioral outcomes associated with ADHD.

Discuss why most current treatments for ADHD have only modest, if any, effects on long-term outcome.

Describe a novel early intervention/prevention program for children with ADHD that is based on the notion that environmental manipulations can impact brain growth and development, which, in turn, may have lasting effects on the severity of ADHD.

Speaker:Jeffrey Halperin is a Distinguished Professor of Psychology at Queens College and the Graduate Center of the City University of New York, Director of the Developmental Neuropsychology Laboratory at Queens College and Director of the Disruptive Behavior Disorders Research Team at the Mount Sinai School of Medicine.

The Multimodal Treatment of ADHD Study (MTA):Questions and Answers

kerch — Tue, 11 Jan 2011 15:04:26 +0000

The Multimodal Treatment of Attention Deficit Hyperactivity Disorder Study (MTA):Questions and Answers

NIMH

Revised November 2009

Attention deficit hyperactivity disorder (ADHD) is the most common psychiatric disorder in childhood. Several interventions are effective in treating children with ADHD, including medications and behavior therapy. To examine how intensive treatment with medications compares with intensive behavior therapy, or with the combination of the two, NIMH sponsored the Multimodal Treatment of ADHD (MTA) study. The main findings from this study were published in December 1999, and are discussed below.

Q. What is the MTA?

A. The MTA was a multisite study designed to evaluate the leading treatments for ADHD, including behavior therapy, medications, and the combination of the two. The study included nearly 600 children, ages 7-9, who were randomly assigned to one of four treatment modes:

intensive medication management alone;
intensive behavioral treatment alone;
a combination of both; or
routine community care (the control group).

Q. Why is the MTA important?

A. While previous studies have examined the safety and compared the effectiveness of medication and behavior therapy for ADHD, they generally were short-term—no more than four months. The MTA study examined for the first time the safety and relative effectiveness of these two treatments—alone and in combination for a time period of up to 14 months, and compared these treatments to routine community care.

Q. What are the major findings of the MTA?

A. The MTA primary results were published in December 1999 in the Archives of General Psychiatry. Combination treatment and medication management alone were both significantly superior to intensive behavioral treatment alone and to routine community care in reducing ADHD symptoms. The study also showed that these benefits last for as long as 14 months.

In other areas of functioning (e.g., anxiety symptoms, academic performance, parent-child relations, and social skills), combination treatment was consistently superior to routine community care, whereas medication alone or behavioral treatment alone were not. The children in the combination treatment also ended up taking lower doses of medication than the children in the medication-alone group. These findings were consistent across all six research sites, despite substantial differences among sites in the children’s sociodemographic characteristics. Therefore, the study’s overall results can apply to a wide range of children and families in need of treatment services for ADHD.

Q. What did the MTA tell us about the safety of stimulant medication?

A. Of the 289 children randomized to medication, 4 percent had adverse effects severe enough to prompt them to discontinue the medication. Adverse effects included loss of appetite, sleep problems, crying spells, and repetitive movements. Medication also slowed the physical growth of children during the 14 months of treatment. The children who received intensive medication treatment (seven days a week) grew 4.25 cm on average and gained 1.64 kg on average, while the children who received behavior therapy only (no medication) grew 6.19 cm on average and gained 4.53 kg on average.¹ Over time, these growth effects may persist if medication is continued.² However, 88 percent of the children were successfully treated for the full duration of the study.

Q. What is the role of behavioral therapy in treating ADHD?

A. Research has shown that behavioral therapies are very effective in treating children with ADHD. However, the MTA study demonstrated that, on average, carefully monitored medication with monthly follow-up is more effective than intensive behavioral treatment alone, for up to 14 months.

All children improved over the course of the study, but they differed in the relative amount of improvement. The children receiving medication management, either alone or in combination with behavior therapy, generally showed the greatest improvement. However, children’s responses varied enormously, and some children did very well in each of the treatment groups.

For some types of functioning, such as academic performance and family relations, the combination of behavioral therapy and medication was superior to the other treatment groups. Therefore, medication alone is not necessarily the best treatment for every child, and families often need to pursue other treatments, either alone or in combination with medication.

Q. Which treatment is right for my child?

A. Parents must consult with their child’s doctor to determine the best course of treatment for their child. No single treatment is best for all children with ADHD. Families should consider side effects of medications, or other circumstances that might render certain treatments inappropriate for their child.

Children with coexisting conditions such as anxiety or external stressors such as high levels of family conflict may do best with a combination of treatments. When determining a suitable treatment, a child’s needs, personal and medical history, and other relevant factors need to be carefully considered.

Q. Why do many social skills improve with medication?

A. Previously, it was thought that children with ADHD could only learn new social skills if they were explicitly taught. However, the MTA study findings suggest that many children can acquire these skills on their own when given the opportunity. Children treated with medication management (either alone or in combination with intensive behavioral therapy) showed more improved social skills and peer relations than children in the community comparison group after 14 months. This finding suggests that symptoms of ADHD may interfere with a child’s ability to learn specific social skills. Medication may help them learn these skills by diminishing symptoms that had previously inhibited the child’s social development.

Q. Why were the MTA medication treatments more effective than community treatments that also usually included medication?

A. There were substantial differences in quality and intensity between the study-provided medication treatments and those provided in the community care group. During the first month of treatment, the MTA doctors worked hard to find the best dose of medication for each child receiving the MTA medication treatment. After this period, the children saw their MTA doctor monthly.

During the treatment visits, the doctor spoke with the parent, met with the child, and worked to determine any concerns that the family might have regarding the medication or the child’s ADHD. If the child was experiencing any difficulties, the MTA doctor could adjust the child’s medication, In contrast, the community treatment doctors generally saw the children face-to-face only one or two times per year.

Careful monitoring also allowed for early detection and response to any side effects from the medication, which probably helped the children stay on the medication. In addition, the MTA doctors consulted with each child’s teacher on a monthly basis, and used this information to make any necessary adjustments in the child’s treatment. In contrast, the community treatment doctors did not interact regularly with the children’s teachers.

Finally, the MTA doctors delivering the medication treatments generally prescribed higher doses of stimulant medications per day than the community treatment doctors.

Q. How were children selected for this study?

A. Parents heard about the study through their pediatricians and other health care providers, their children’s teachers, or through radio/newspaper announcements. They then contacted the investigators. Study investigators interviewed the children and parents to learn more about the nature of the child’s symptoms and medical history, and rule out other conditions or factors that may be causing the child’s difficulties. The children needed to meet strict criteria to be eligible for the study.

Q. What are the main limitations of the MTA, and what happened after it concluded?

A. The MTA was designed and conducted in the early 1990s, before the extended release formulations of stimulant medications became widely available. The MTA used immediate release methylphenidate (Ritalin), which was administered three times a day. Currently, most children receiving stimulant treatment for ADHD are given a once-a-day dose of medication in the morning. However, this difference in medication administration does not change the study’s main conclusions.

In addition, the MTA treatment lasted for 14 months only, after which the children were referred back to their community providers. Some of them continued treatment. Others discontinued their treatment or changed it, based on their individual situation. All participants, regardless of the treatment they received, were invited to return to the MTA clinics every one to two years for an assessment of their ADHD symptoms and level of functioning.

Because their treatment after the end of the study was not controlled, it is not possible to draw accurate conclusions about the effectiveness of interventions beyond 14 months, or determine if treatment improves long-term functioning. However, the observations collected from these uncontrolled follow-up assessments can provide information about the long-term course of ADHD itself. These data are being analyzed and reported as they become available.³

Q. Where did this study take place?

A. The study was conducted at the following clinical research sites:

New York State Psychiatric Institute at Columbia University, New York, NY.
Mount Sinai Medical Center, New York, NY
Duke University Medical Center, Durham, NC
University of Pittsburgh, Pittsburgh, PA
Long Island Jewish Medical Center, New Hyde Park, NY
Montreal Children’s Hospital, Montreal, Canada
University of California at Berkeley, CA
University of California at Irvine, CA

Q. Where can I find more information about the MTA study?

A. In addition to the information available on the NIMH Web site on MTA the following is a selection of MTA references:

The MTA Cooperative Group: A 14-Month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder (ADHD). Arch Gen Psychiatry 1999;56:1073-1086.
The MTA Cooperative Group: Moderators and mediators of treatment response for children with attention-deficit/hyperactivity disorder (ADHD). Arch Gen Psychiatry 1999;56:1088-1096.
Swanson JM, Kraemer HC, Hinshaw SP, Arnold LE, Conners CK, Abikoff HB, Clevenger W, Davies M, Elliott GR, Greenhill LL, Hechtman L, Hoza, B, Jensen PS, March JS, Newcorn JH, Owens EB, Pelham WE, Schiller E, Severe JB, Simpson S, Vitiello B, Wells K, Wigal T, Wu M: Clinical relevance of the primary findings of the MTA: success rate based on severity of ADHD and ODD symptoms at the end of treatment. J Am Acad Child Adolesc Psychiatry 2001; 40:168-179.
Greenhill LL, Swanson JM, Vitiello B, Davies M, Clevenger W, Wu M, Arnold LE, Abikoff HB, Bukstein OG, Conners CK, Elliott GR, Hechtman L, Hinshaw SP, Hoza B, Jensen PS, Kraemer HC, March JS, Newcorn JH, Severe JB, Wells K, WigalT: Impairment and deportment responses to different methylphenidate doses in children with ADHD: the MTA titration trial. J Am Acad Child Adolesc Psychiatry 2001; 40:180-187.
Vitiello B, Severe JB, Greenhill LL, Arnold LE, Abikoff HB, Bukstein O, Elliott GR, Hechtman L, Jensen PS, Hinshaw SP, March JS, Newcorn JH, Swanson JM, Cantwell DP: Methylphenidate Dosage for Children with ADHD over Time under Controlled Conditions: Lessons from the MTA. J Am Acad Child Adolesc Psychiatry 2001; 40:188-196.
Owens EB, Hinshaw SP, Kraemer HC, Arnold LE, Abikoff HB, Cantwell DP, Conners CK, Elliot G, Greenhill LL, Hechtman L, Hoza B, Jensen PS, March JS, Newcorn JH, Pelham WE, Richters JE, Schiller EP, Severe JB, Swanson JM, Vereen D, Vitiello B, Wells KC, Wigal T: What treatment for whom for ADHD: Moderators of treatment response in the MTA. J Consult Clin Psychol2003;71:540-552.
MTA Cooperative Group: National Institute of Mental Health Multimodal Treatment Study of ADHD follow-up: 24-month outcomes of treatment strategies for attention-deficit/hyperactivity disorder. Pediatrics 2004;113:754-761.
MTA Cooperative Group: National Institute of Mental Health Multimodal Treatment Study of ADHD follow-up: changes in effectiveness and growth after the end of treatment. Pediatrics 2004;113:762-769.
Swanson JM, Elliott GR, Greenhill LL, Wigal T, Arnold LE, Vitiello B, Hechtman L, Epstein J, Pelham W, Abikoff HB, Newcorn J, Molina B, Hinshaw S, Wells K, Hoza B, Severe JB, Jensen PS, Gibbons R, Hur K, Stehli A, Davies M, March J, Caron M, Volkow ND, Posner MI, for the MTA Cooperative Group: Effects of stimulant medication on growth rates across 3 years in the MTA follow-up. J Am Acad Child Adolesc Psychiatry 2007;46:1014-1026.
Molina BSG, Hinshaw S.P., Swanson J.M., Arnold, L.E., Vitiello B, Jensen PS, Epstein JN, Hoza B, Hechtman L., Abikoff, H.B., Elliott GR, Greenhill LL, Newcorn, JH, Wells KC, Wigal TL, Severe JB, Gibbons RD, Hur K, Houck PR, and the MTA Cooperative Group: The MTA at 8 years: prospective follow-up of children treated for combined type ADHD in a multisite study. J Am Acad Child Adolesc Psychiatry 2009;48:484-500.

Citations

¹MTA Cooperative Group: National Institute of Mental Health Multimodal Treatment Study of ADHD follow-up: changes in effectiveness and growth after the end of treatment. Pediatrics 2004;113:762-769.

²Swanson JM, Elliott GR, Greenhill LL, Wigal T, Arnold LE, Vitiello B, Hechtman L, Epstein J, Pelham W, Abikoff HB, Newcorn J, Molina B, Hinshaw S, Wells K, Hoza B, Severe JB, Jensen PS, Gibbons R, Hur K, Stehli A, Davies M, March J, Caron M, Volkow ND, Posner MI, for the MTA Cooperative Group: Effects of stimulant medication on growth rates across 3 years in the MTA follow-up. J Am Acad Child Adolesc Psychiatry 2007;46:1014-1026.

³Molina BSG, Hinshaw S.P., Swanson J.M., Arnold, L.E., Vitiello B, Jensen PS, Epstein JN, Hoza B, Hechtman L., Abikoff, H.B., Elliott GR, Greenhill LL, Newcorn, JH, Wells KC, Wigal TL, Severe JB, Gibbons RD, Hur K, Houck PR, and the MTA Cooperative Group: The MTA at 8 years: prospective follow-up of children treated for combined type ADHD in a multisite study. J Am Acad Child Adolesc Psychiatry 2009;48:484-500.

ADD Resource Center » Research

Caring for Children with ADHD: A Resource Toolkit for Clinicians

ADHD – NICHQ Toolkit

National Initiative for Children’s Healthcare Quality

Diagnosis

Treatment

Parent Information and Support

Resources

ADHD Assessment Tools

ADHD medications show no association with heart events

Safety Announcement

ADHD medications involved in this safety review

Stimulants

Non-stimulants

Related Information

ADHD Statistics

NCHS Data Brief

Attention Deficit Hyperactivity Disorder Among Children Aged 5–17 Years in the United States, 1998–2009

On This Page

Key findings

The percentage of children ever diagnosed with ADHD increased from 1998 through 2009 among both boys and girls.

ADHD prevalence varied by race and ethnicity, but differences between most groups narrowed from 1998 through 2009.

From 1998 through 2009, ADHD prevalence increased for children with family income less than 100% of the poverty level and for those with family income between 100% and 199% of the poverty level.

ADHD prevalence rose in the Midwest and South regions of the United States from 1998 through 2009.

Summary

Definitions

Data source and methods

About the authors

References

Suggested citation

Copyright information

National Center for Health Statistics

Office of Analysis and Epidemiology

Prevalence and correlates of adult ADHD in the United States

ADHD and Emotional Regulation Video by Dr. Russell A. Barkley

ADHD Data and Statistics in THE USA

Data & Statistics

In the United States

State-based Prevalence Data of ADHD Diagnosis (2007-2008)

Medication Treatment

State-based Prevalence Data of ADHD Medication Treatment (2003)

Diagnosed Attention Deficit Hyperactivity Disorder and Learning Disability: United States, 2004-2006

Peer Relationships

Injury

Economic Cost

Footnotes:

This page in

High IQ Kids With ADHD – Thomas E. Brown, Ph.D.

Bright students are not immune from the cognitive difficulties that plague other children and adolescents with attention deficit disorder, a new Yale study has found.

For the complete report: High-IQ-Kids-with-ADHD

Development of Preventive Interventions for ADHD (Audio)

No longer science fiction: The Development of Preventive Interventions for ADHD

The Multimodal Treatment of ADHD Study (MTA):Questions and Answers

The Multimodal Treatment of Attention Deficit Hyperactivity Disorder Study (MTA):Questions and Answers

Revised November 2009

Q. What is the MTA?

Q. Why is the MTA important?

Q. What are the major findings of the MTA?

Q. What did the MTA tell us about the safety of stimulant medication?

Q. What is the role of behavioral therapy in treating ADHD?

Q. Which treatment is right for my child?

Q. Why do many social skills improve with medication?

Q. Why were the MTA medication treatments more effective than community treatments that also usually included medication?

Q. How were children selected for this study?

Q. What are the main limitations of the MTA, and what happened after it concluded?

Q. Where did this study take place?

Q. Where can I find more information about the MTA study?

Citations