This project is ongoing and does not have results.
The Patient-Centered Outcomes Research Institute (PCORI) is partnering with the Agency for Healthcare Research and Quality (AHRQ) to update a systematic evidence review on diagnosis and treatment for attention deficit hyperactivity disorder (ADHD) in children and adolescents. The American Academy of Pediatrics, the nominator of the 2018 AHRQ systematic review, will partner with PCORI in this endeavor with the hope that the results of the update will provide valuable insight for future guidelines for the diagnosis and treatment of ADHD.
ADHD is a chronic neurobehavioral disorder consisting of a pattern of inattention and/or hyper-impulsivity more frequent and severe than typically observed in individuals of comparable developmental levels and is among the most common disorders of childhood. Children with ADHD often present with a number of behavioral, social, and academic concerns. The effects of these concerns can be persistent, and most individuals experience appreciable symptoms into adulthood. Early and effective treatment may be helpful in improving long-term outcomes.
Estimates of ADHD prevalence vary across diagnostic criteria, evaluation methods, and populations, with recent estimates indicating that 2 percent to 9.5 percent of school-aged children and adolescents have ADHD. In the United States, a national survey conducted in 2016 found 9.4 percent of children aged 2-17 years had a diagnosis of ADHD. ADHD is more prevalent among boys than girls, with boys more than twice as likely to receive an ADHD diagnosis. Approximately one-third of children are diagnosed before 6 years of age, most frequently by their primary care provider or pediatrician. ADHD is most common in non-Hispanic White (10.75 percent) and Black (9.85 percent) children, but differences across race/ethnicity for diagnosis are generally thought to be an artifact of underdiagnosis and undertreatment of Black and Hispanic children.
Management options for ADHD include pharmacologic and nonpharmacologic treatments, used alone or in combination. Pharmacologic treatments include stimulant and nonstimulant medications, with methylphenidate (a stimulant) generally recommended as the first-line option. Nonpharmacologic interventions for the treatment of ADHD encompass behavioral interventions, parent training, school-based interventions, social skills training, neurofeedback, physical activity, dietary interventions, vitamins and supplements, mindfulness, and other alternative therapies. Children receiving treatment for ADHD should be monitored regularly by a primary care provider for adherence to treatment plan, response to treatment, and any adverse effects. The frequency of monitoring visits depends on the use of pharmacologic treatment and how well the child responds to the treatment plan.
The American Academy of Pediatrics published a clinical practice guideline in 2019 on the diagnosis, evaluation, and treatment of ADHD in children and adolescents, which was informed by the 2018 AHRQ systematic review. Since then, findings from many new trials have been released, particularly pertaining to the treatment of ADHD and focused on nonpharmacologic treatment. Consequently, the Academy is interested in an update of the systematic review of diagnosis and treatment for ADHD in children and adolescents.
Draft Key Questions
1. For the diagnosis of ADHD:
- What is the comparative diagnostic accuracy of approaches that can be used in the primary care practice setting or by specialists to diagnose ADHD among individuals younger than 7 years of age?
- What is the comparative diagnostic accuracy of EEG, imaging, or approaches assessing executive function that can be used in the primary care practice setting or by specialists to diagnose ADHD among individuals aged 7 through 17?
- For both populations, how does the comparative diagnostic accuracy of these approaches vary by clinical setting, including primary care or specialty clinic, or patient subgroup, including age, sex, or other risk factors associated with ADHD?
- What are the adverse effects associated with being labeled correctly or incorrectly as having ADHD?
2. What are the comparative safety and effectiveness of pharmacologic and/or nonpharmacologic treatments of ADHD in improving outcomes associated with ADHD? How do these outcomes vary by presentation (inattentive, hyperactive/impulsive, and combined) or other comorbid conditions? What is the risk of diversion of pharmacologic treatment?
3. What are the comparative safety and effectiveness of different monitoring strategies to evaluate the effectiveness of treatment or changes in ADHD status (e.g., worsening or resolving symptoms)?
Draft Key Questions
Posted for public comment (on the AHRQ Effective Healthcare website)