Council Report Diagnosis and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents Larry S. Goldman, MD; Myron Genel, MD; Rebecca J. Bezman, MD; Priscilla J. Slanetz, MD, MPH; for the Council on Scientific Affairs, American Medical Association Objective.—To deal with public and professional concern regarding possible overprescription of attention-deficit/hyperactivity disorder (ADHD) medications, particularly methylphenidate, by reviewing issues related to the diagnosis, optimal treatment, and actual care of ADHD patients and of evidence of patient misuse of ADHD medications. Data Sources.—Literature review using a National Library of Medicine database search for 1975 through March 1997 on the terms attention deficit disorder with hy- peractivity, methylphenidate, stimulants, and stimulant abuse and dependence. Rel- evant documents from the Drug Enforcement Administration were also reviewed. Study Selection.—All English-language studies dealing with children of elemen- tary school through high school age were included. Data Extraction.—All searched articles were selected and were made available to coauthors for review. Additional articles known to coauthors were added to the initial list, and a consensus was developed among the coauthors regarding the ar- ticles most pertinent to the issues requested in the resolution calling for this report. Relevant information from these articles was included in the report. Data Synthesis.—Diagnostic criteria for ADHD are based on extensive empirical research and, if applied appropriately, lead to the diagnosis of a syndrome with high interrater reliability, good face validity, and high predictability of course and medi- cation responsiveness. The criteria of what constitutes ADHD in children have broadened, and there is a growing appreciation of the persistence of ADHD into ado- lescence and adulthood. As a result, more children (especially girls), adolescents, and adults are being diagnosed and treated with stimulant medication, and children are being treated for longer periods of time. Epidemiologic studies using standard- ized diagnostic criteria suggest that 3% to 6% of the school-aged population (el- ementary through high school) may suffer from ADHD, although the percentage of US youth being treated for ADHD is at most at the lower end of this prevalence range. Pharmacotherapy, particularly use of stimulants, has been extensively studied and generally provides significant short-term symptomatic and academic improvement. There is little evidence that stimulant abuse or diversion is currently a major problem, particularly among those with ADHD, although recent trends suggest that this could increase with the expanding production and use of stimulants. Conclusions.—Although some children are being diagnosed as having ADHD with insufficient evaluation and in some cases stimulant medication is prescribed when treatment alternatives exist, there is little evidence of widespread overdiag- nosis or misdiagnosis of ADHD or of widespread overprescription of methylpheni- date by physicians. JAMA. 1998;279:1100-1107 From the Council on Scientific Affairs, American Medical Association, Chicago, Ill. This report was presented at the 1997 House of Del- egates Annual Meeting as Report 5 of the Council on Scientific Affairs. The recommendations were adopted, and the remainder of the report was filed. This report is not intended to be construed or to serve as a standard of medical care. Standards of medical care are determined on the basis of all the facts and circumstances involved in an individual case and are subject to change as scientific knowledge and technology advance and patterns of practice evolve. This report reflects the scientific literature as of March 1997. Reprints: Linda B. Bresolin, PhD, Council on Scientific Affairs, American Medical Association, 515 N State St, Chicago, IL 60610 (e-mail: linda_bresolin@ama-assn .org). ATTENTION-DEFICIT/hyperactiv- ity disorder (ADHD) is a common neu- ropsychiatric syndrome with onset in childhood, most commonly becoming ap- parent (and thus coming to medical at- tention) during the first few years of grade school. ADHD may be associated with a number of comorbid psychiatric conditions as well as with impaired aca- demic performance and with both pa- tient and family emotional distress. While it was previously thought that the dis- order remitted before or during adoles- cence, it has become well established that many patients will have an illness course that persists well into adulthood. Phar- macological treatment, particularly with stimulant medication, is the most- studied aspect of management, al- though other forms of treatment (eg, be- havior therapy, parent training) are important parts of good clinical care. Despite an enormous body of research into this disorder, various aspects of ADHD have generated controversy over the years. Three features of ADHD in particular seem to have contributed to the controversy: (1) like most mental dis- orders, its diagnostic criteria involve pa- tient history and behavioral assessment without the availability of laboratory or radiologic confirmation; (2) like many chronic illnesses of childhood, it has an early onset and extended course, thus requiring at times treatment of children and adolescents over many years; and (3) its treatment often includes stimu- lant medications that have abuse or di- version potential. Members of the Council on Scientific Affairs at the time this report was written include the following: Mitchell S. Karlan, MD, Los Angeles, Calif (chair); Ronald M. Davis, MD, Detroit, Mich (chair-elect); Roy D. Altman, MD, Miami, Fla; Rebecca J. Bezman, MD, Chicago, Ill; Scott D. Deitchman, MD, MPH, Decatur, Ga; Myron Genel, MD, New Haven, Conn; John P. Howe III, MD, San Antonio, Tex; Nancy H. Nielsen, MD, PhD, Buffalo, NY; Joseph A. Riggs, MD, Haddon Field, NJ; Priscilla J. Slanetz, MD, MPH, Boston, Mass; Michael A. Williams, MD, Baltimore, Md; Donald C. Young, MD, Iowa City; Larry S. Goldman, MD (staff); Robert C. Rinaldi, PhD (secretary); Linda Bresolin, PhD (assistant secretary). 1100 JAMA, April 8, 1998—Vol 279, No. 14 ADHD in Children and Adolescents—Goldman et al ©1998 American Medical Association. All rights reserved. at WOFFORD COLLEGE, on September 10, 2007 www.jama.com Downloaded from