Formal training in parenting strategies is a low-risk, effective method for improving behavior in preschool-age children at risk for developing attention deficit hyperactivity disorder (ADHD), while there is less evidence supporting the use of medications for children younger than 6 years old, according to a new report from the U.S. Department of Health and Human Services' Agency for Healthcare Research and Quality (AHRQ).
The report found that formal parenting interventions—known as parent behavior training or PBT—are supported by strong evidence for effectiveness for children younger than the age of 6, with no reports of complications or harms. However, one large barrier to the success of PBT is parents who drop out of therapy programs, the report found. For children older than age 6, the report found that methylphenidate (sold under the brand name Ritalin) and another drug used to treat ADHD symptoms, atomoxetine (sold as Strattera), are generally safe and effective for improving behavior, but their effects beyond 12 to 24 months have not been well studied. Little information is available about the long-term effects of other medications used to treat ADHD symptoms.
The report, a comparative effectiveness review prepared for AHRQ's Effective Health Care Program by the McMaster Evidence-based Practice Center in Hamilton, Ontario, is available at www.effectivehealthcare.ahrq.gov.
"ADHD can place many challenges on families with young and school-age children," said AHRQ Director Carolyn M. Clancy, M.D. "This new report and these summary publications will help children, parents and their doctors work together to find the best treatment option based on the family's values, preferences and needs."
Children with ADHD, a condition characterized by inattention, overactivity and impulsivity, are most frequently identified and treated in primary school. It is estimated that approximately 5 percent of children worldwide exhibit behavior consistent with ADHD, with boys twice as likely to be classified as having ADHD than girls.
However, identification and management of ADHD can be challenging, and diagnosis and treatment vary greatly depending on geography and culture. Many preschool-age children who exhibit aggressive or noncompliant behavior and may eventually develop ADHD initially receive a more general diagnosis of disruptive behavior disorder.
Ritalin was first used in the 1950s to treat disruptive behavior, and the use of drug-based treatment has increased since then, along with refinements in understanding and recognition of ADHD as a disorder. By 1999, approximately 11 million prescriptions for Ritalin were written annually in the United States, with another 6 million prescriptions written for amphetamines. There has been ongoing uncertainty about accurate diagnosis of ADHD and potential overprescription of Ritalin and other drugs, particularly in recent years as drug treatment has spread to other populations.
In the past 25 years, four major PBT methods have been developed. These programs are designed to help parents manage their child's problem behavior with more effective discipline strategies using rewards and nonpunitive consequences. Each promotes a positive and caring relationship between parents and their child, and seeks to improve both child behavior and parenting skills.
The AHRQ report found that these PBT interventions are effective, with no reported risk of complications for preschool-age children with disruptive behavior disorder, including ADHD. For older children, the report found that methylphenidate and atomoxetine are effective in controlling ADHD symptoms without significant risk of harms for up to 2 years, although research on longer-term effectiveness and possible adverse effects is sparse.
The report, "Attention Deficit Hyperactivity Disorder: Effectiveness of Treatment in At-Risk Preschoolers; Long-Term Effectiveness in All Ages; and Variability in Prevalence, Diagnosis, and Treatment," is the latest comparative effectiveness review from AHRQ's Effective Health Care Program. The Effective Health Care Program helps patients, doctors, nurses, pharmacists and others choose the most effective treatments by sponsoring the development of evidence reports and technology assessments to assist public- and private-sector organizations in their efforts to improve the quality of health care in the United States.
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