CPG on ADHD

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measurements of social skills, which indicates that there is no positive influence of the stimulantmedication on the social skills at the end of the treatment or during follow-up.In the measurementsof the emotional state (depression, anxiety, emotional adjustment and internalized symptoms),the stimulant medication was more effective than the psychological intervention at the end ofthe treatment, but the effect size was small and limited in the parents’ measurements, with noeffect in the teachers’ measurements.The lack of scientific evidence of the sustained superiority of the medication overpsychological intervention for ADHD is difficult to interpret.For longer follow-ups in time,the results can be influenced by the treatment that the child has received since the end of theexperimental intervention period.In particular, children that received psychological interventionand were not medicated for ADHD during the trial period were able to start to receive medicationfor ADHD later on.In the MTA study, 44% of the children of the group that only receivedpsychological intervention during the study had started stimulant medication after the 10-monthfollow-up.22 months after the end of the treatment, 45% of the children had started stimulantmedication.Summary of the scientific evidenceAlthough there is scientific evidence about the superiority of the pharmacologicalintervention with respect to the psychological intervention, when stimulantmedication is compared with complex psychological intervention (as offeredin the MTA study), the benefits of the medication respect to the psychologicaltreatment are weak (NICE, 2009) 2 .RCT1++Cost-effectiveness studiesSummary of the scientific evidenceThe NICE <strong>CPG</strong> (2009) 2 has reviewed the available scientific evidence oneconomic cost-effectiveness studies for pharmacological and psychologicaltreatment and a treatment combination in children with ADHD: Lord & Paisley2000 323 , Zupancic, et al., 1998 290 .The NICE economic model was also used, about the use of methylphenidate,atomoxetine and dexamphetamine in children with ADHD via a subanalysisthat compared the combination of interventions with the medications evaluated(King, et al., 2006) 201 .An economic analysis of the interventions assessed in the MTA study wasreviewed separately (MTA 1999) 39 : Jensen, et al., 2005 324 ; Foster, et al.,2007325.Lord & Paisley (2000) 323 performed an economic analysis that compared thecost-effectiveness of the combination of interventions with psychologicaltherapy alone for children with ADHD in the United Kingdom, based on thedata of the MTA study(1999) 39 , the results favour the combined treatment.However, due to methodological limitations, these results must be appraisedwith caution.Cost-effectivenessstudies1+, 1++Cost-effectivenessstudies1+144 CLINICAL PRACTICE GUIDELINE ON ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD) IN CHILDREN AND ADOLESCENTS
The scientific evidence of Zupancic, et al. (1998) 290 suggests that combined andpsychological therapy is not a cost-effective option compared with medicationfor children with ADHD. However, there are limitations in the clinicaleffectiveness of the data used in the analysis.The review of the economic analysis of King et al.(2006) 201 suggests thatgroup behavioural therapy is more cost-effective than combined treatment andmedication for children with ADHD. On the other hand, medication is morecost-effective than individual behavioural therapy. Combined therapy was notcost-effective in the studies reviewed.The review by Jensen et al.(2005) 324 and Foster, et al. (2007) 325 on the MTAstudy (MTA 1999) 39 concludes that, for children with ADHD, the managementof the medication, although not so effective as the combined therapy, is a morecost-effective option, above all for children with associated comorbid disorders.For children with comorbid ADHD with both internalizedand externalisingdisorders, they suggest that the combined treatment is relatively cost-effective.The medication management was the most suitable option from the costeffectivenessviewpoint, compared with intensive behavioural treatment andcombined treatment.Cost-effectivenessstudies1+Cost-effectivenessstudies1++Cost-effectivenessstudies1++Different reasons why it is advisable to use multimodal treatment forADHD (NICE, 2009) 2There are several reasons why non-pharmacological treatment, normally psychological treatment,can be combined with pharmacological treatment:• When psychological intervention is the option preferred by children and adolescents,and their families, but due to the seriousness of the symptoms, this may not be feasibleat that time.However, the medication’s potential to provide a fast initial improvementover the first few weeks of a combined intervention may help them benefit from thepsychological techniques later on.• In serious cases, it may be advisable to start the pharmacological treatment in order tooffer more immediate improvement effects. This may be necessary if there is a markedsocial dysfunction, a lot of pressure from the family or companion, if the child is facingan impending school expulsion.• Behavioural learning in psychological treatment may be favoured by the combined useof pharmacological treatment.• Combining pharmacological treatment with psychological intervention may lead to areduction in the drug doses and also in concerns about the use of the medication.RecommendationsB 7.4.2.1.In children and adolescents with moderate or serious ADHD, combinedtreatment is recommended, which includes behavioural psychologicaltreatment, pharmacological treatment and psychopedagogicalintervention at school.CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS 145
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Clinical Practice Guidelineon Atten
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This CPG has been
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AppendicesAppendix 1 Levels of evid
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We trust that this work will undoub
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Jesús Eirís Puñal, neuropaediatr
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Questions to be answeredADHD1. How
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39. In which ADHD subtypes is pharm
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Recommendations of the CPG<
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6. Assessment instruments6.1. Which
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7.2.3. Pyschopedagogical re-educati
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7.3.7. In ADHD: How long should the
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7.3.13. What scientific evidence ex
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B 7.5.3.2.In children and adolescen
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9.4. How involved must the minor be
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1. IntroductionBackgroundThe “Evi
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Table 1. ADHD prevalence studies in
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Health RepercussionsThe repercussio
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Secondary objectivesa) To generate
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• Formulation of clinical questio
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evidence have been solved by consen
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ment.At school age, the hyperactive
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Volumetric brain studies have shown
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4.4. What is the natural course of
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Parents’ psychopathologyIn the st
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5. DiagnosisQuestions to be answere
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A SR conducted by the NICE guidelin
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Family backgroundSummary of scienti
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5.4. In the diagnosis of ADHD in ch
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5.7. In the diagnosis of ADHD in ch
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6.1. Which screening instruments an
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Title Authors Year Description Age
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Title Authors Year Description Age
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RecommendationsC 6.1.1. 6.1.2. 6.2.
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6.5. In ADHD in children and adoles
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7. Treatment7.1. Psychological trea
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Variable: ADHD symptomsScientific e
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Variable: Internalized symptomsScie
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The scientific evidence about the e
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Variable: Social skillsScientific e
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7.1.4. How effective is the psychol
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7.2. Psychopedagogical TreatmentQue
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• Working on habits that foster a
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Teacher’s adaptationsScientific e
Page 95 and 96: Scientific evidenceThere is not suf
Page 97 and 98: 7.3. Pharmacological treatmentQuest
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Page 101 and 102: AtomoxetineThis is a non-stimulant
Page 103 and 104: 7.3.2. In ADHD: What pharmacologica
Page 105 and 106: There is strong scientific evidence
Page 107 and 108: Variable: Behavioural problemsScien
Page 109 and 110: There is not sufficient scientific
Page 111 and 112: BupropionThe NICE CPG</stro
Page 115 and 116: Summary of the scientific evidence
Page 117 and 118: 7.3.4. In ADHD: When and with what
Page 119 and 120: MethylphenidateSummary of the scien
Page 121 and 122: AtomoxetineSummary of the scientifi
Page 123 and 124: The consensus of the American Heart
Page 125 and 126: In a RCT that studied the efficacy
Page 127 and 128: 7.3.13. What scientific evidence ex
Page 129 and 130: 7.3.15. Does the efficacy of pharma
Page 131 and 132: Recommendations 7.3.17.1. 7.3.17.2.
Page 133 and 134: Scientific evidenceThe scientific e
Page 139 and 140: There is limited scientific evidenc
Page 141 and 142: The combined intervention of MTA is
Page 143 and 144: There is limited scientific evidenc
Page 145: There is not sufficient scientific
Page 149 and 150: RecommendationsC 7.5.1.1.The use of
Page 151 and 152: Summary of the scientific evidenceT
Page 153 and 154: Summary of the scientific evidenceT
Page 155 and 156: Elimination interventions include t
Page 157 and 158: Auditory stimulationThis is based o
Page 159: 8. PreventionGiven the mainly genet
Page 162 and 163: Recommendations 9.1.1.In the specif
Page 164 and 165: Recommendations 9.4.1.Applicableleg
Page 166 and 167: 10. Diagnostic and therapeutic stra
Page 168 and 169: Algorithm 3. Pharmacological treatm
Page 171 and 172: 11. Dissemination and implementatio
Page 173 and 174: 12. Future research recommendations
Page 175: home, at school or in the recreatio
Page 178 and 179: Appendix 1: Evidence levels and rec
Page 180 and 181: Impulsivitya) Often blurts out answ
Page 182 and 183: Appendix 3. Information for patient
Page 184 and 185: 3. How does ADHD evolve with age?In
Page 186 and 187: 5.1. Psychological treatment for AD
Page 188 and 189: What drugs are available in Spain?A
Page 190 and 191: Is pharmacological treatment for AD
Page 192 and 193: 10. What can be done from school to
Page 194 and 195: Appendix 4. GlossaryAGREE: Instrume
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and mental operations, self-regulat
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tions that are to be compared.The r
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Appendix 5. AbbreviationsAACAPAAPAD
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MAMFF_20mgMHSMSCAMTA StudyNICENIMHN
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Appendix 6. Declaration of interest
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Alicia Koplowitz Foundation, Jansse
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Health Care Guideline: Diagnosis an
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Attention deficit hyperactivity dis
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tionario de Conners en nuestro medi
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50. Quinn P, Wigal S. Perceptions o
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twin study: preliminary report. 199
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Number 3, August 1999. Agency for H
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controlled trial of integrated home
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Improvement. Clinical Practice Guid
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Adolesc Psychiatry. 2006 Nov;45(11)
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Acad Child Adolesc Psychiatry. 1995
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omized, double-blind, placebo-contr
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300. Wilens TE, Newcorn JH, Kratoch
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functioning pervasive developmental
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P.V.P.: 10 €MINISTERIODE SANIDAD,
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