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Treatment of attention-deficit/hyperactivity disorder.

Abstract

OBJECTIVES

To determine (a) the long-term and short-term effectiveness and safety of pharmacological and nonpharmacological interventions for attention-deficit/hyperactivity disorder (ADHD) in children and adults and (b) whether combined interventions are more effective than individual interventions.

SEARCH STRATEGY

MEDLINE (from 1966), CINAHL (from 1982), HEALTHStar (from 1975), PsycINFO (from 1984), EMBASE (from 1984), and the Cochrane Library searches were completed in November 1997. Reference lists of eligible studies and files of members of the research team and partner organizations were also searched.

SELECTION CRITERIA

Studies were selected if they focused on the treatment of ADHD in humans and were published in any language as a full report in peer-reviewed journals. Studies including conditions other than ADHD were reported if separate subgroup analyses for patients with ADHD were provided.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data for 41 variables on general characteristics, along with detailed information on interventions, outcomes, and tests. Differences were resolved by consensus or by a third researcher. Studies were not combined quantitatively because the quality of reporting was low and heterogeneity existed across outcome measures and tests.

MAIN RESULTS

Seventy-eight studies (77 randomized controlled trials) met the inclusion criteria. Twenty-three studies compared drugs and showed few, if any, differences among methylphenidate (MPH), dextroamphetamine (DEX), and pemoline; studies comparing stimulants with tricyclic antidepressants (2) were inconclusive. Six studies compared drugs with nondrug interventions and showed consistently that stimulants, particularly MPH, may be more effective than nonpharmacological interventions. Twenty studies compared combination therapies with a stimulant or a nondrug intervention alone; no additional beneficial effects for combination therapies were shown. Nine studies compared tricyclic antidepressants with placebo and showed that desipramine may be more effective than placebo; no consistent effect was shown for imipramine. Fourteen studies (13 in school children and 1 in adults) evaluated long-term therapy (> or = 12 weeks) and showed a trend to general improvement regardless of treatment, but the length of followup was inadequate. MPH may reduce behavioral disturbance in children with ADHD while it is taken. Academic performance does not appear to be improved with stimulants. Twelve studies evaluated treatment in adults with ADHD. For MPH vs. placebo, the results were contradictory. Antidepressants may be effective in adults, but no beneficial effect was seen with pemoline, nicotine, or phenylalanine compared with placebo. Thirty-two reports (29 studies) evaluated adverse effects of drug therapy; many of the side effects associated with stimulant use appear to be relatively mild and of short duration and to respond to dosing or timing adjustments. Data are inadequate on the long-term effects and severity of adverse effects of most interventions.

CONCLUSIONS

This report describes rigorous systematic reviews on the treatment of ADHD, ready for incorporation into evidence-based clinical practice guidelines or performance measures. The report also provides a detailed description of the many limitations of the evidence available and provides recommendations to fill existing knowledge gaps. Studies on ADHD have low reporting quality, methodological flaws, and heterogeneity across outcome measures and tests. A detailed description is included of the many limitations of the available evidence plus recommendations to fill existing knowledge gaps. Fulfilling such knowledge gaps will not be easy and will require genuine collaboration among decisionmakers.

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  • Authors+Show Affiliations

    ,

    McMaster University, Hamilton, Ontario, Canada.

    , , ,

    Source

    MeSH

    Adrenergic Uptake Inhibitors
    Adult
    Antidepressive Agents, Tricyclic
    Attention Deficit Disorder with Hyperactivity
    Central Nervous System Stimulants
    Child
    Child Behavior
    Combined Modality Therapy
    Desipramine
    Dextroamphetamine
    Evidence-Based Medicine
    Follow-Up Studies
    Humans
    Imipramine
    Methylphenidate
    Nicotine
    Nicotinic Agonists
    Pemoline
    Phenylalanine
    Placebos
    Randomized Controlled Trials as Topic
    Safety
    Treatment Outcome

    Pub Type(s)

    Comparative Study
    Journal Article
    Meta-Analysis
    Research Support, Non-U.S. Gov't

    Language

    eng

    PubMed ID

    10790990

    Citation

    Jadad, A R., et al. "Treatment of Attention-deficit/hyperactivity Disorder." Evidence Report/technology Assessment (Summary), 1999, pp. i-viii, 1-341.
    Jadad AR, Boyle M, Cunningham C, et al. Treatment of attention-deficit/hyperactivity disorder. Evid Rep Technol Assess (Summ). 1999.
    Jadad, A. R., Boyle, M., Cunningham, C., Kim, M., & Schachar, R. (1999). Treatment of attention-deficit/hyperactivity disorder. Evidence Report/technology Assessment (Summary), (11), pp. i-viii, 1-341.
    Jadad AR, et al. Treatment of Attention-deficit/hyperactivity Disorder. Evid Rep Technol Assess (Summ). 1999;(11)i-viii, 1-341. PubMed PMID: 10790990.
    * Article titles in AMA citation format should be in sentence-case
    TY - JOUR T1 - Treatment of attention-deficit/hyperactivity disorder. AU - Jadad,A R, AU - Boyle,M, AU - Cunningham,C, AU - Kim,M, AU - Schachar,R, PY - 2000/5/3/pubmed PY - 2000/5/20/medline PY - 2000/5/3/entrez SP - i-viii, 1-341 JF - Evidence report/technology assessment (Summary) JO - Evid Rep Technol Assess (Summ) IS - 11 N2 - OBJECTIVES: To determine (a) the long-term and short-term effectiveness and safety of pharmacological and nonpharmacological interventions for attention-deficit/hyperactivity disorder (ADHD) in children and adults and (b) whether combined interventions are more effective than individual interventions. SEARCH STRATEGY: MEDLINE (from 1966), CINAHL (from 1982), HEALTHStar (from 1975), PsycINFO (from 1984), EMBASE (from 1984), and the Cochrane Library searches were completed in November 1997. Reference lists of eligible studies and files of members of the research team and partner organizations were also searched. SELECTION CRITERIA: Studies were selected if they focused on the treatment of ADHD in humans and were published in any language as a full report in peer-reviewed journals. Studies including conditions other than ADHD were reported if separate subgroup analyses for patients with ADHD were provided. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data for 41 variables on general characteristics, along with detailed information on interventions, outcomes, and tests. Differences were resolved by consensus or by a third researcher. Studies were not combined quantitatively because the quality of reporting was low and heterogeneity existed across outcome measures and tests. MAIN RESULTS: Seventy-eight studies (77 randomized controlled trials) met the inclusion criteria. Twenty-three studies compared drugs and showed few, if any, differences among methylphenidate (MPH), dextroamphetamine (DEX), and pemoline; studies comparing stimulants with tricyclic antidepressants (2) were inconclusive. Six studies compared drugs with nondrug interventions and showed consistently that stimulants, particularly MPH, may be more effective than nonpharmacological interventions. Twenty studies compared combination therapies with a stimulant or a nondrug intervention alone; no additional beneficial effects for combination therapies were shown. Nine studies compared tricyclic antidepressants with placebo and showed that desipramine may be more effective than placebo; no consistent effect was shown for imipramine. Fourteen studies (13 in school children and 1 in adults) evaluated long-term therapy (> or = 12 weeks) and showed a trend to general improvement regardless of treatment, but the length of followup was inadequate. MPH may reduce behavioral disturbance in children with ADHD while it is taken. Academic performance does not appear to be improved with stimulants. Twelve studies evaluated treatment in adults with ADHD. For MPH vs. placebo, the results were contradictory. Antidepressants may be effective in adults, but no beneficial effect was seen with pemoline, nicotine, or phenylalanine compared with placebo. Thirty-two reports (29 studies) evaluated adverse effects of drug therapy; many of the side effects associated with stimulant use appear to be relatively mild and of short duration and to respond to dosing or timing adjustments. Data are inadequate on the long-term effects and severity of adverse effects of most interventions. CONCLUSIONS: This report describes rigorous systematic reviews on the treatment of ADHD, ready for incorporation into evidence-based clinical practice guidelines or performance measures. The report also provides a detailed description of the many limitations of the evidence available and provides recommendations to fill existing knowledge gaps. Studies on ADHD have low reporting quality, methodological flaws, and heterogeneity across outcome measures and tests. A detailed description is included of the many limitations of the available evidence plus recommendations to fill existing knowledge gaps. Fulfilling such knowledge gaps will not be easy and will require genuine collaboration among decisionmakers. SN - 1530-440X UR - https://www.unboundmedicine.com/medline/citation/10790990/Treatment_of_attention_deficit/hyperactivity_disorder_ L2 - https://www.ncbi.nlm.nih.gov/books/NBK33078 DB - PRIME DP - Unbound Medicine ER -