australian guidelines on attention deficit hyperactivity disorder

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Australian Guidelines on

Attention DeficitHyperactivity Disorder

(ADHD)

Systematic Review

November 2008


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Introduction

This document presents research collated to inform the Guidelines for attention deficit

hyperactivity disorder (ADHD) 2008. The research questions and tables are organised to reflect

the order of the guidelines. Each table provides the lead author, a brief description of the sampleand the design, a brief description of the intervention or diagnostic criteria, the outcome measures

used and a brief conclusion. Readers are recommended to read the original articles for more

details.

Funding

The Royal Australasian College of Physicians gratefully acknowledges the financial assistance

for the development of these guidelines, which was provided by the Australian Government

Department of Health and Ageing.


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Table of Contents

LIST OF RESEARCH QUESTIONS.........................................................................................................................4

LITERATURE REVIEW METHODS.......................................................................................................................7

ASSESSMENT AND DIAGNOSIS......... ............ .............. ............ ............. .............. ............ ............ .............. ........... 11

MEASURES OF IMPAIRMENT......................................................................................................................................11

RETROSPECTIVE RECALL OF CHILDHOOD ADHD SYMPTOMS ...................................................................................17PARENT AND TEACHER REPORTS .............................................................................................................................. 21SELF AND THIRD-PARTY REPORTS.............................................................................................................................29PARENT REPORTS -BIAS ..........................................................................................................................................35NEUROPSYCHOLOGICAL ASSESSMENT MEASURES ....................................................................................................39NEUROPHYSIOLOGICAL MEASURES ..........................................................................................................................51NEUROIMAGING ....................................................................................................................................................... 59

PSYCHOSOCIAL MANAGEMENT............. .............. ............ ............. ............ .............. ............ .............. ............. .. 62PSYCHOSOCIAL INTERVENTIONS............................................................................................................................... 62PARENTING PROGRAMS ............................................................................................................................................71MODERATORS AND MEDIATORS OF OUTCOMES FOR PSYCHOSOCIAL INTERVENTIONS............................................... 77PSYCHOSOCIAL INTERVENTIONS WHEN COMORBIDITIES ARE PRESENT .....................................................................81

MEDICATION MANAGEMENT........... .............. ............ .............. ............. ............ ............ .............. ............. ......... 85STIMULANT MEDICATION .........................................................................................................................................85LONG TERM USE OF STIMULANT MEDICATIONS.........................................................................................................94STIMULANT MEDICATION - SIDE EFFECTS ................................................................................................................. 97ATOMOXETINE .......................................................................................................................................................105ATOMOXETINE - LONG TERM USE ...........................................................................................................................108ATOMOXETINE SIDE EFFECTS .................................................................................................................................111OTHER MEDICATIONS .............................................................................................................................................115COMPARING MEDICATIONS.....................................................................................................................................127WHEN COMORBIDITIES ARE PRESENT .....................................................................................................................139IMPACT OF MEDICATION ON TICS ...........................................................................................................................152WHEN DEVELOPMENTAL DISABILITIES ARE PRESENT .............................................................................................160ADVERSE EVENTS GROWTH .................................................................................................................................166ADVERSE EVENTS CARDIAC .................................................................................................................................175ADVERSE EVENTS PSYCHIATRIC ..........................................................................................................................181ADHD MEDICATIONS AND SUBSTANCE ABUSE.......................................................................................................185TREATMENT OF ADHD AND COMORBID SUBSTANCE ABUSE DISORDERS................................................................191

MEDICATION COMPARED TO AND COMBINED WITH OTHER STRATEGIES ............ .............. ......... 195

COMPARING PSYCHOSOCIAL AND PHARMACOLOGICAL INTERVENTIONS ................................................................195COMBINING PSYCHOSOCIAL AND PHARMACOLOGICAL INTERVENTIONS .................................................................201

MANAGEMENT IN AN EDUCATION SETTING..............................................................................................209SCHOOL-BASED INTERVENTIONS ............................................................................................................................209PEER SUPPORT AND MENTORING.............................................................................................................................216INTERVENTIONS IN ADULT EDUCATION SETTINGS...................................................................................................219

COMPLIMENTARY AND ALTERNATIVE MANAGEMENT STRATEGIES..............................................220

ELIMINATION AND RESTRICTION DIETS...................................................................................................................220FATTY ACID SUPPLEMENTS.....................................................................................................................................223CHIROPRACTIC .......................................................................................................................................................226BEHAVIOURAL OPTOMETRY ...................................................................................................................................227BIOFEEDBACK ........................................................................................................................................................228HOMEOPATHY ........................................................................................................................................................233CEREBELLAR THERAPY...........................................................................................................................................235 EXCERISE, MEDITATION AND RELAXATION.............................................................................................................237SENSORY INTEGRATION INTERVENTIONS ................................................................................................................240

ADHD AND SOCIETY............................................................................................................................................242

REFERENCES .........................................................................................................................................................245


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List of research questions

Assessment and Diagnosis1. In individuals suspected of having ADHD does the use of measures of impairment, in additionto DSM-IV/ICD10, further inform diagnosis and assessment?

2. In adolescents and adults with ADHD are retrospective self-reports of symptoms in childhoodaccurate?

3. In preschoolers, children or adolescents with ADHD is there consensus between parent andteacher reports of ADHD symptoms when assessed with parallel instruments?

4. In individuals with ADHD is there consensus between third party (parent, teacher or familymember) and self-reports of ADHD symptoms when assessed with parallel instruments?

5. In preschoolers, children or adolescents with ADHD does the psychiatric status of the parentinfluence parent reports in the diagnosis and assessment for ADHD?

6. In individuals suspected of having ADHD does the inclusion of neuropsycholgical assessmentmeasures, in addition to DSM-IV/ICD10, further inform diagnosis and assessment?

7. In individuals suspected of having ADHD does the inclusion of neurophysiological techniques,in addition to DSM-IV/ICD10, further inform diagnosis?

8. In individuals suspected of having ADHD does the inclusion of neuroimaging techniques, inaddition to DSM-IV/ICD10, further inform diagnosis?

Management: Psychosocial interventions

9. For individuals with ADHD, do psychosocial interventions, compared to no intervention orstandard care, affect outcomes?

10. For preschoolers, children and adolescents with ADHD, does behaviour management in theform of parent training, compared to no intervention or standard care, affect outcomes?

11. For individuals with ADHD, what are the moderators and mediators of treatment responsewith psychosocial interventions?

12. When comorbidities are present in individuals with ADHD, do psychosocial interventions,compared to no intervention or standard care, affect outcomes?

Management: Medication13a. For individuals with ADHD, do stimulant pharmacological interventions, compared withplacebo, improve outcomes?

13b. For individuals with ADHD does the use of stimulant medications for 1 year or more,compared with placebo or standard care, affect outcomes?

13c. For individuals with ADHD who are taking stimulant medication, what are the main sideeffects?


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14a. For individuals with ADHD, does the use of atomoxetine, compared with placebo, improveoutcomes?

14b. For individuals with ADHD does the use of atomoxetine for 1 year or more, compared withplacebo or standard care, affect outcomes?

14c. For individuals with ADHD who are taking atomoxetine, what are the main side effects?

15. For individuals with ADHD, do other pharmacological interventions compared with placebo,affect outcomes?

a. Clonidineb. Modafinilc. Selegilined. Guanfacinee. Nicotine patchf. Bupropiong. Risperidone

16. For individuals with ADHD, do any pharmacological interventions confer an advantage overany other pharmacological interventions?

17a. When comorbidities are present in individuals with ADHD, do pharmacologicalinterventions, compared to placebo improve outcomes?

a. Anxietyb. Bipolor disorderc. Depressiond. Disruptive behaviour disordere. Epilepsyf. Tic disorders Tourette syndrome

17b. For individuals with ADHD who are taking medication, what is the risk of developing first-onset tics or worsening existing tics?

17c. When developmental disabilities are present in individuals with ADHD, do pharmacologicalinterventions, compared to placebo improve outcomes?

a. Learning disordersb. Developmental or intellectual disabilitiesc. Autism spectrum disorders

18. For preschoolers, children and adolescents with ADHD who are taking medication, what isthe risk of impaired growth?

19. For individuals with ADHD who are taking medication, what is the risk of cardiovascularproblems?

20. For individuals with ADHD who are taking medication, what is the risk of psychiatricadverse effects?

21. For individuals with ADHD, does the use of pharmacological interventions, compared to nointervention, alter the risk for substance abuse or medication misuse?


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22. For individuals with ADHD and substance use disorders do pharmacological or psychosocialinterventions, affect outcomes?

Management: Medication compared to and combined with other strategies23. For individuals with ADHD, do psychosocial interventions compared to pharmacologicalinterventions, affect outcomes?

24. For individuals with ADHD, do psychosocial interventions used alongside pharmacologicalinterventions, compared with pharmacological interventions alone, affect outcomes?

Management in an Education Setting

25. For children and adolescents with ADHD, do school-based interventions, compared to nointervention or standard care, affect outcomes?

26. For children and adolescents with ADHD, do peer support, tutoring or mentoring, comparedto no intervention or standard care, affect outcomes?

27. For adults with ADHD, do University/TAFE-based interventions, that address ADHD,compared to no intervention or standard care, affect outcomes?

Management: complimentary and alternative strategies

28. For individuals with ADHD, do diet restrictions (artificial colours, artificial flavours andpreservatives), compared with no intervention or standard care, affect outcomes?

29. For individuals with ADHD, does diet supplementation with fatty acids, compared withplacebo or standard care, affect outcomes?

30. For individuals with ADHD, does chiropractics, compared with no intervention or standardcare, affect outcomes?

31. For individuals with ADHD, does behavioural optometry, compared with no intervention orstandard care, affect outcomes?

32. For individuals with ADHD, does biofeedback, compared with no intervention or standardcare, affect outcomes?

33. For individuals with ADHD, does homeopathy, compared with no intervention or standardcare, affect outcomes?

34. For individuals with ADHD, do cerebellar therapies (such as the Dore program), comparedwith no intervention or standard care, affect outcomes?

35. For individuals with ADHD, does participation in sport or exercise programmes, comparedwith no intervention or standard care, affect outcomes?

36. For individuals with ADHD, do sensory diets / sensory integrative treatments, compared withno intervention, affect outcomes?


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ADHD in society

37. For individuals with ADHD, does the use of interventions (pharmacological, psychosocial orother), compared with no intervention, improve driving performance?

Literature review methods

The aim of this systematic literature review is to assist in the development of guidelines for theassessment, treatment and care of individuals with ADHD. The methods used in the systematicreview comply with NHMRC requirements (1-4).

Literature searchesA comprehensive literature search for relevant research using multiple databases as well asinternet searching, pearling and hand searches was carried out for each research question (Table1). The literature review was designed to update the 1997 NHMRC Guidelines on ADHD. Theliterature searches were conducted to encompass the years1997 - 2007. Research publicationsmeeting the NHMRC designated levels of evidence I-IV were sought (4). In the first instance asearch was conducted to identify any systematic reviews or meta-analyses that were available toaddress each research question (Level I). If a systematic review or meta-analysis addressing the

research question was not identified the search limits were extended to include Level II evidence.In the absence of Level I or II evidence, Level III and IV evidence was sought. Search strategiesfor systematic reviews / meta-analyses and randomised controlled trials are described in Table 2.The searches for each question were conducted by one reviewer. Twenty percent of the searcheswere independently conducted and checked for agreement by a second reviewer.

Inclusion and exclusion criteria

A set of individual inclusion and exclusion criteria were developed for each research questionbased on study population, intervention, comparator, relevant outcomes, study design, searchperiod and language.

For all questions the identified studies were excluded on the following rationale. Animal studies Inadequate outcome data presented Review articles with no original data Sample size of less than 10 participants The article could not be located Articles that fall outside the NHMRC designated levels of evidence I-IV.


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Table 1. Search methods and databases

Electronic Databases

The Cochrane LibraryCochrane Database of Systematic Reviews (CDSR)Cochrane Database of Abstracts of Reviews of Effects (DARE)The Health Technology Assessment Database (HTA)

Cochrane Central Register of Controlled Trials (CENTRAL)Cumulative Index to Nursing and Allied Health Literature (CINAHL)Excerpta Medica Database (EMBASE)MedlinePsycInfoClinical EvidenceCurrent Controlled Trials metaRegister; http://controlled trials.com/The Centre for Reviews and Dissemination (CRD); http://www.york.ac.uk/inst/crd/Health Technology Assessment international http://www.htai.org/Education databasesERICProQuest Education JournalsCriminology databases

Criminal justice abstractsCriminology : a SAGE full-text collectionPearling

The reference lists of all included articles was searched for additional relevant studiesSearches of Topic Specific Internet Sites

Australian Psychological Society; http//www.psychology.org.auAmerican Psychiatric Association; http://www.psych.org/search.cfmAmerican Academy of Child and Adolescent Psychiatry; http://www.aacap.org/European Society for Child and Adolescent Psychiatry; http://www.escap-net.org/National Institute of Mental Health; http://www.nimh.nih.gov/nimhhome/index.cfm

Table 2. Standardised search strategies: based on the OVID interface for Medline

Search strategy for systematic reviews Search strategy for randomised controlled trials

1. (systematic adj review*).tw.2. (data adj synthesis).tw.3. (published adj studies).ab.4. (data adj extraction).ab.5. meta-analysis/6. meta-analysis.ti.7. guideline.pt.8. practice guideline.pt.9. comment.pt.10. letter.pt.11.editorial.pt.12.animal/13.human/14.12 not (12 and 13)15.ADHD search terms16.other search terms17.combined search18.17 not (9 or 10 or 11 or 14)19.or/1-820.18 and 19

1. (randomised controlled trial).pt2. (controlled clinical trial).pt3. (randomised controlled trial).tw4. rct.tw5. (double blind method).tw6. (single blind method).tw7. (clinical adj trial).tw8. or/1-7


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Study Selection Process

1. All citations identified for each question or for a designated group of questions werecollated into an Endnote database and duplicate references were removed.

2. The title and abstract of these citations were screened for relevance. Studies thatwould clearly not meet the inclusion criteria were excluded at the level of title andabstract.

3. The remaining studies were retrieved for assessment of the full-text.4. The inclusion and exclusion criteria were applied to each retrieved article by two

independent reviewers. Articles that did not meet the inclusion criteria followingassessment of the full-text were excluded and are listed with the reasons for exclusionwith each question. Articles that met the inclusion criteria were included for data-extraction and critical appraisal.

Data-Extraction and Critical appraisalData were extracted into standardised data-extraction / critical appraisal tables. The internal andexternal validity of all included studies was critically appraised based on the NHMRC criticalappraisal checklists (1) and the NHMRC interim levels and grades of evidence (4). In addition,the modified Overview Quality Assessment Questionnaire (OQAQ) (5-7) was used to assess thequality of systematic reviews and meta-analysis. The data-extraction / critical appraisal tables foreach included study are available from the RACP on request.


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Table 3. Number of articles at each step for each question.

Q Number of

articles identified

for screening

Number of

articles excluded

at the title and

abstract level

Number of full-

text articles

retrieved for

consideration

Number of

articles included

1 116 98 18 7

2-5 507 448 2. 113. 234. 155. 10

2. 73. 134. 105. 5

6 163 131 32 227 113 97 17 118 17 12 5 29 392 363 29 10

10 97 82 15 611 Q9-10 screened - 9 412 Q9-10 screened - 10 3

13-19 533 289 13a. 2613b. 1813c. 2514a. 1114b. 1114c. 1315. 4316. 2717a. 5217b. 2817c. 2218. 2119. 1320. 5

13a. 1613b. 113c. 1114a. 214b. 214c. 515. 1616. 1517a. 1717b. 1117c. 618. 1419. 920. 3

21-22 279 25923.

1324. 723.

724. 423 Q9-22 screened - 8 524 Q9-22 screened - 13 10

25-26 189 145 25. 626. 38

25. 326. 12

27 21 18 3 028 25 21 4 329 63 55 8 330 15 14 1 131 10 10 0 032 59 46 13 633 35 34 1 1

34 16 12 4 135 42 34 8 336 83 81 2 137 69 69 0 038 66 62 4 439 196 190 6 3

17c** 159 149 10 1** Expanded search on treatment of ADHD and comorbid learning disorders conducted

separately in August 2008.


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Assessment and diagnosis

Measures of impairment

Research question

1: In individuals with ADHD does the inclusion of measures of impairment, in addition to DSM-IV/ICD10, further inform diagnosis and assessment?

Sub question: Can measures of impairment distinguish between impaired and unimpairedindividuals with ADHD?

Selection Criteria Inclusion Criteria

Population Individuals with ADHD

Indicator Measures of impairment

Comparator Individuals without ADHD

Outcomes Diagnostic utility: predictive value and sensitivity & specificityAbility to identify individuals with ADHD at high risk for functional

impairment.

Study Design NHMRC I-IV for diagnostic studies

Search Period 1997 - present considered

Language English

Date of Search March 2008

Search terms

MeSH: Text words:Attention deficit disorder withhyperactivity/

adhd or addh or adhs or hyperactive$ orhyperkin$ or (attention adj deficit)impairment or adaptive impairment or

executive function$Diagnosis/ or diagnosis, differential/ orassessment or predictive value of tests/ orsensitivity and specificity/

questionnaires/ or rating scale$


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Preschoolers

Reference Diagnostic

instruments

Population/Study information Results

Lahey et al2004 (8)

DesignDiagnosticcase-controlstudy

Level III-3

SettingUSA(clinical)

Industry

fundingNo

Diagnostic toolDiagnostic

interview forchildren andparents;ImpairmentRating Scale

Population: 3.87.0-year-oldchildren who met DSM-IV criteria

for ADHD and children withoutADHD

Full ADHD: meets DSM-IVsymptom criteria and has cross-situational impairment.

Situational ADHD: meets DSM-IVsymptom criteria and hasimpairment in one situation (homeor school ).

Study information:Design: case-controlDuration: 3 years (yearlyassessment waves 1-4).

Recruitment:Clinic attendees and community

No. n (control subjects) = 130n (children with situationalADHD) = 29n (children with full ADHD) = 96

Outcome Measures:1. Chi-square (Full ADHD vs noADHD; situation ADHD vs noADHD; full ADHD vs situationalADHD)

The full ADHD group exhibitedsignificantly greater global, academic,

and social impairment during waves 24 than the situational ADHD group (p

australian guidelines on attention deficit hyperactivity disorder

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