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ADHD Diagnosis and Treatment in Children and Adolescents
Comparative Effectiveness Review, No. 267
Investigators: Bradley S. Peterson, M.D., Joey Trampush, Ph.D., Margaret Maglione, M.P.P., Maria Bolshakova, B.S., Ph.D., Morah Brown, M.P.H., Mary Rozelle, P.A., Aneesa Motala, B.A., Sachi Yagyu, M.L.S., Jeremy Miles, Ph.D., Sheila Pakdaman, Ph.D., Mario Gastelum, M.P.H., Bich Thuy (Becky) Nguyen, M.P.H., Erin Tokutomi, M.P.H., Esther Lee, M.P.H. candidate, Jerusalem Z. Belay, M.P.H., Coleman Schaefer, M.P.H., Benjamin Coughlin, M.P.H., Karin Celosse, Psy.D, M.S.C.P., M.P.H., Sreya Molakalapalli, M.P.H., Brittany Shaw, M.P.H. candidate, Tanzina Sazmin, M.P.H., M.B.B.S., Anne N. Onyekwuluje, M.D., M.P.H., Danica Tolentino, M.S., and Susanne Hempel, Ph.D.
Abstract
Objective:
The systematic review assessed evidence on the diagnosis, treatment, and monitoring of attention deficit hyperactivity disorder (ADHD) in children and adolescents to inform a planned update of the American Academy of Pediatrics (AAP) guidelines.
Data sources:
We searched PubMed®, Embase®, PsycINFO®, ERIC, clinicaltrials.gov, and prior reviews for primary studies published since 1980. The report includes studies published to June 15, 2023.
Review methods:
The review followed a detailed protocol and was supported by a Technical Expert Panel. Citation screening was facilitated by machine learning; two independent reviewers screened full text citations for eligibility. We abstracted data using software designed for systematic reviews. Risk of bias assessments focused on key sources of bias for diagnostic and intervention studies. We conducted strength of evidence (SoE) and applicability assessments for key outcomes. The protocol for the review has been registered in PROSPERO (CRD42022312656).
Results:
Searches identified 23,139 citations, and 7,534 were obtained as full text. We included 550 studies reported in 1,097 publications (231 studies addressed diagnosis, 312 studies addressed treatment, and 10 studies addressed monitoring). Diagnostic studies reported on the diagnostic performance of numerous parental ratings, teacher rating scales, teen/child self-reports, clinician tools, neuropsychological tests, EEG approaches, imaging, and biomarkers. Multiple approaches showed promising diagnostic performance (e.g., using parental rating scales), although estimates of performance varied considerably across studies and the SoE was generally low. Few studies reported estimates for children under the age of 7. Treatment studies evaluated combined pharmacological and behavior approaches, medication approved by the Food and Drug Administration, other pharmacologic treatment, psychological/behavioral approaches, cognitive training, neurofeedback, neurostimulation, physical exercise, nutrition and supplements, integrative medicine, parent support, school interventions, and provider or model-of-care interventions. Medication treatment was associated with improved broadband scale scores and ADHD symptoms (high SoE) as well as function (moderate SoE), but also appetite suppression and adverse events (high SoE). Psychosocial interventions also showed improvement in ADHD symptoms based on moderate SoE. Few studies have evaluated combinations of pharmacological and youth-directed psychosocial interventions, and we did not find combinations that were systematically superior to monotherapy (low SoE). Published monitoring approaches for ADHD were limited and the SoE is insufficient.
Conclusion:
Many diagnostic tools are available to aid the diagnosis of ADHD, but few monitoring strategies have been studied. Medication therapies remain important treatment options, although with a risk of side effects, as the evidence base for psychosocial therapies strengthens and other nondrug treatment approaches emerge.
Contents
- Preface
- Acknowledgments
- Key Informants
- Technical Expert Panel
- Peer Reviewers
- Executive Summary
- 1. Introduction
- 2. Methods
- 3. Results: Description of Included Evidence
- 4. Results: Diagnosis of ADHD
- 4.1. KQ1, ADHD Diagnosis Key Points
- 4.2. KQ1, ADHD Diagnosis Summary of Findings
- 4.3. Summary ADHD Diagnosis by Tests for All Age Groups
- 4.4. KQ1a. 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?
- 4.5. KQ1b. 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?
- 4.6. KQ1c. 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?
- 4.7. KQ1d. What are the adverse effects associated with being labeled correctly or incorrectly as having ADHD?
- 4.8. Summary of Findings. KQ1a–d
- 5. Results: Treatment of ADHD
- 5.1. KQ2, ADHD Treatment Key Points
- 5.2. KQ2, ADHD Treatment Results
- 5.3. Effects by Intervention
- 5.4. KQ2a. How do these outcomes vary by presentation (inattentive, hyperactive/impulsive, and combined) or other co-occurring conditions?
- 5.6. KQ2b. What is the risk of diversion of pharmacologic treatment?
- 5.7. Summary of Findings KQ2a and KQ2b
- 6. Results: Monitoring ADHD
- 7. Discussion
- References
- Abbreviations and Acronyms
- Appendixes
Suggested citation:
Peterson BS, Trampush J, Maglione M, Bolshakova M, Brown M, Rozelle M, Motala A, Yagyu S, Miles J, Pakdaman S, Gastelum M, Nguyen BT, Tokutomi E, Lee E, Belay JZ, Schaefer C, Coughlin B, Celosse K, Molakalapalli S, Shaw B, Sazmin T, Onyekwuluje AN, Tolentino D, Hempel S. ADHD Diagnosis and Treatment in Children and Adolescents. Comparative Effectiveness Review No. 267. (Prepared by the Southern California Evidence-based Practice Center under Contract No. 75Q80120D00009.) AHRQ Publication No. 24-EHC003. PCORI Publication No. 2023-SR-03. Rockville, MD: Agency for Healthcare Research and Quality; March 2024. DOI: https://doi.org/10.23970/AHRQEPCCER267. Posted final reports are located on the Effective Health Care Program search page.
This report is based on research conducted by the Southern California Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 75Q80120D00009). The Patient-Centered Outcomes Research Institute® (PCORI®) funded the report (PCORI® Publication No. 2023-SR-03). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ or PCORI®, its Board of Governors or Methodology Committee. Therefore, no statement in this report should be construed as an official position of PCORI®, AHRQ, or the U.S. Department of Health and Human Services.
None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report.
The information in this report is intended to help healthcare decision makers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of healthcare services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.
This report is made available to the public under the terms of a licensing agreement between the author and the Agency for Healthcare Research and Quality. Most AHRQ documents are publicly available to use for noncommercial purposes (research, clinical or patient education, quality improvement projects) in the United States, and do not need specific permission to be reprinted and used unless they contain material that is copyrighted by others. Specific written permission is needed for commercial use (reprinting for sale, incorporation into software, incorporation into for-profit training courses) or for use outside of the U.S. If organizational policies require permission to adapt or use these materials, AHRQ will provide such permission in writing.
PCORI®, AHRQ, or U.S. Department of Health and Human Services endorsement of any derivative products that may be developed from this report, such as clinical practice guidelines, other quality enhancement tools, or reimbursement or coverage policies, may not be stated or implied.
A representative from AHRQ served as a Contracting Officer’s Representative and reviewed the contract deliverables for adherence to contract requirements and quality. AHRQ did not directly participate in the literature search, determination of study eligibility criteria, data analysis, interpretation of data, or preparation or drafting of this report.
AHRQ and PCORI® appreciate appropriate acknowledgment and citation of their work. Suggested language for acknowledgment: This work was based on an evidence report, ADHD Diagnosis and Treatment in Children and Adolescents, by the Evidence-based Practice Center Program at the Agency for Healthcare Research and Quality (AHRQ) and funded by PCORI®.
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