The Frontiers of Research About Attention-Deficit/Hyperactivity Disorder Mark L. Wolraich, MD
Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees. www.pediatrics.org/cgi/doi/10.1542/peds.2015-0070 DOI: 10.1542/peds.2015-0070 Accepted for publication Jan 15, 2015 Address correspondence to Mark L. Wolraich, MD, University of Oklahoma Child Development Center, 1100 NE 13th St, Oklahoma City, OK 73116. E-mail: [email protected] PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2015 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The author has indicated he has no financial relationships relevant to this article to disclose. FUNDING: No external funding. POTENTIAL CONFLICT OF INTEREST: The author has indicated he has no potential conflicts of interest to disclose. COMPANION PAPER: A companion to this article can be found on page e858, online at www.pediatrics. org/cgi/doi/10.1542/peds.2014-3221.
COMMENTARY
Despite the clear and strong short-term efficacy of both psychotropic medications and behavioral therapies in treating individuals with attentiondeficit/hyperactivity disorder (ADHD),1 treatment has not led to long-term outcomes that are comparable to those of individuals who do not have ADHD.2 Even with intensive multimodalitytreatment of ADHD1 to provide optimal medication management therapy, behavioral therapy, or both combined, by 2 years after the intense efforts ended, the results of those efforts could not be distinguished from each other or from those for children who received their usual community services.3 A longitudinal study from Rochester, MN, found that adults with ADHD identified in childhood and followed until they were young adults continued to fair less well than a comparison typical group in their school performance and job achievement, and they even had a higher suicide rate.2 On average, the individuals had remained on medication for 3 years during their childhood. The discrepancy between the promising short-term effects and the less-than-optimal long-term effects may be because neither form of therapy is curative for most individuals with ADHD, so interventions need to be sustained. Therefore, an important aspect of treatment research that has yet to be adequately studied are programs that increase adherence and address the changing needs of children with ADHD as they mature. The study reported in this issue by Silverstein et al4 examining the effects
of a collaborative care model is a good example of using rigorous methods to examine a specific approach systematically and to test an element of that intervention, namely, training in motivational interviewing. The study used symptom reduction as outcome measures. Future studies can be further enhanced by including assessments from the parents’ and patients’ perspectives. In addition, it will be important to include cost analysis as part of the studies and variances in health service delivery systems to reflect different regions of the country and differences between urban and rural settings. We have much to learn about how we can design interventions that are both effective and sustainable over time and how therapies have to be adapted to meet the needs of children as they mature. We have to develop better measures to monitor the progress of children with ADHD in the functional areas of home, school, and society. It is also important to better understand the issues of transition that children with ADHD face as they progress from grade school to postsecondary education and into adulthood. As progress is being made in better understanding the neurologic processes and genetic underpinnings of ADHD, therapy is likely to remain symptomatic and not curative for a while. It is only through more systematic, longitudinal, and rigorous investigations that we are likely to translate the success of the current short-term benefits of psychotropic
Downloaded from pediatrics.aappublications.org at Nyu Medical Center on May 27, 2015
PEDIATRICS Volume 135, number 4, April 2015
medications and behavioral therapy into positive long-term outcomes. REFERENCES 1. Jensen PS, Hinshaw SP, Swanson JM, et al. Findings from the NIMH Multimodal Treatment Study of ADHD (MTA): implications and applications for primary care providers. J Dev Behav Pediatr. 2001;22(1):60–73
2. Barbaresi WJ, Colligan RC, Weaver AL, Voigt RG, Killian JM, Katusic SK. Mortality, ADHD, and psychosocial adversity in adults with childhood ADHD: a prospective study. Pediatrics. 2013; 131(4):637–644 3. Molina BS, Hinshaw SP, Swanson JM, et al; MTA Cooperative Group. The MTA at 8 years: prospective follow-up of children treated for combined-type
ADHD in a multisite study. J Am Acad Child Adolesc Psychiatry. 2009;48(5): 484–500 4. Silverstein M, Hironaka LK, Walter HJ, et al. Collaborative care for children with ADHD symptoms: a randomized comparative effectiveness trial. Pediatrics. 2015;135(4). Available at: www.pediatrics.org/cgi/content/full/134/ 4/e858
Downloaded from pediatrics.aappublications.org at Nyu Medical Center on May 27, 2015
PEDIATRICS Volume 135, number 4, April 2015
e1043
The Frontiers of Research About Attention-Deficit/Hyperactivity Disorder Mark L. Wolraich Pediatrics 2015;135;e1042; originally published online March 23, 2015; DOI: 10.1542/peds.2015-0070 Updated Information & Services
including high resolution figures, can be found at: http://pediatrics.aappublications.org/content/135/4/e1042.full. html
References
This article cites 3 articles, 1 of which can be accessed free at: http://pediatrics.aappublications.org/content/135/4/e1042.full. html#ref-list-1
Subspecialty Collections
This article, along with others on similar topics, appears in the following collection(s): Focus on Subspecialties http://pediatrics.aappublications.org/cgi/collection/focus
Permissions & Licensing
Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://pediatrics.aappublications.org/site/misc/Permissions.xh tml
Reprints
Information about ordering reprints can be found online: http://pediatrics.aappublications.org/site/misc/reprints.xhtml
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2015 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
Downloaded from pediatrics.aappublications.org at Nyu Medical Center on May 27, 2015
The Frontiers of Research About Attention-Deficit/Hyperactivity Disorder Mark L. Wolraich Pediatrics 2015;135;e1042; originally published online March 23, 2015; DOI: 10.1542/peds.2015-0070
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pediatrics.aappublications.org/content/135/4/e1042.full.html
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2015 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
Downloaded from pediatrics.aappublications.org at Nyu Medical Center on May 27, 2015
Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees. www.pediatrics.org/cgi/doi/10.1542/peds.2015-0070 DOI: 10.1542/peds.2015-0070 Accepted for publication Jan 15, 2015 Address correspondence to Mark L. Wolraich, MD, University of Oklahoma Child Development Center, 1100 NE 13th St, Oklahoma City, OK 73116. E-mail: [email protected] PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2015 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The author has indicated he has no financial relationships relevant to this article to disclose. FUNDING: No external funding. POTENTIAL CONFLICT OF INTEREST: The author has indicated he has no potential conflicts of interest to disclose. COMPANION PAPER: A companion to this article can be found on page e858, online at www.pediatrics. org/cgi/doi/10.1542/peds.2014-3221.
COMMENTARY
Despite the clear and strong short-term efficacy of both psychotropic medications and behavioral therapies in treating individuals with attentiondeficit/hyperactivity disorder (ADHD),1 treatment has not led to long-term outcomes that are comparable to those of individuals who do not have ADHD.2 Even with intensive multimodalitytreatment of ADHD1 to provide optimal medication management therapy, behavioral therapy, or both combined, by 2 years after the intense efforts ended, the results of those efforts could not be distinguished from each other or from those for children who received their usual community services.3 A longitudinal study from Rochester, MN, found that adults with ADHD identified in childhood and followed until they were young adults continued to fair less well than a comparison typical group in their school performance and job achievement, and they even had a higher suicide rate.2 On average, the individuals had remained on medication for 3 years during their childhood. The discrepancy between the promising short-term effects and the less-than-optimal long-term effects may be because neither form of therapy is curative for most individuals with ADHD, so interventions need to be sustained. Therefore, an important aspect of treatment research that has yet to be adequately studied are programs that increase adherence and address the changing needs of children with ADHD as they mature. The study reported in this issue by Silverstein et al4 examining the effects
of a collaborative care model is a good example of using rigorous methods to examine a specific approach systematically and to test an element of that intervention, namely, training in motivational interviewing. The study used symptom reduction as outcome measures. Future studies can be further enhanced by including assessments from the parents’ and patients’ perspectives. In addition, it will be important to include cost analysis as part of the studies and variances in health service delivery systems to reflect different regions of the country and differences between urban and rural settings. We have much to learn about how we can design interventions that are both effective and sustainable over time and how therapies have to be adapted to meet the needs of children as they mature. We have to develop better measures to monitor the progress of children with ADHD in the functional areas of home, school, and society. It is also important to better understand the issues of transition that children with ADHD face as they progress from grade school to postsecondary education and into adulthood. As progress is being made in better understanding the neurologic processes and genetic underpinnings of ADHD, therapy is likely to remain symptomatic and not curative for a while. It is only through more systematic, longitudinal, and rigorous investigations that we are likely to translate the success of the current short-term benefits of psychotropic
Downloaded from pediatrics.aappublications.org at Nyu Medical Center on May 27, 2015
PEDIATRICS Volume 135, number 4, April 2015
medications and behavioral therapy into positive long-term outcomes. REFERENCES 1. Jensen PS, Hinshaw SP, Swanson JM, et al. Findings from the NIMH Multimodal Treatment Study of ADHD (MTA): implications and applications for primary care providers. J Dev Behav Pediatr. 2001;22(1):60–73
2. Barbaresi WJ, Colligan RC, Weaver AL, Voigt RG, Killian JM, Katusic SK. Mortality, ADHD, and psychosocial adversity in adults with childhood ADHD: a prospective study. Pediatrics. 2013; 131(4):637–644 3. Molina BS, Hinshaw SP, Swanson JM, et al; MTA Cooperative Group. The MTA at 8 years: prospective follow-up of children treated for combined-type
ADHD in a multisite study. J Am Acad Child Adolesc Psychiatry. 2009;48(5): 484–500 4. Silverstein M, Hironaka LK, Walter HJ, et al. Collaborative care for children with ADHD symptoms: a randomized comparative effectiveness trial. Pediatrics. 2015;135(4). Available at: www.pediatrics.org/cgi/content/full/134/ 4/e858
Downloaded from pediatrics.aappublications.org at Nyu Medical Center on May 27, 2015
PEDIATRICS Volume 135, number 4, April 2015
e1043
The Frontiers of Research About Attention-Deficit/Hyperactivity Disorder Mark L. Wolraich Pediatrics 2015;135;e1042; originally published online March 23, 2015; DOI: 10.1542/peds.2015-0070 Updated Information & Services
including high resolution figures, can be found at: http://pediatrics.aappublications.org/content/135/4/e1042.full. html
References
This article cites 3 articles, 1 of which can be accessed free at: http://pediatrics.aappublications.org/content/135/4/e1042.full. html#ref-list-1
Subspecialty Collections
This article, along with others on similar topics, appears in the following collection(s): Focus on Subspecialties http://pediatrics.aappublications.org/cgi/collection/focus
Permissions & Licensing
Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://pediatrics.aappublications.org/site/misc/Permissions.xh tml
Reprints
Information about ordering reprints can be found online: http://pediatrics.aappublications.org/site/misc/reprints.xhtml
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2015 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
Downloaded from pediatrics.aappublications.org at Nyu Medical Center on May 27, 2015
The Frontiers of Research About Attention-Deficit/Hyperactivity Disorder Mark L. Wolraich Pediatrics 2015;135;e1042; originally published online March 23, 2015; DOI: 10.1542/peds.2015-0070
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pediatrics.aappublications.org/content/135/4/e1042.full.html
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2015 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
Downloaded from pediatrics.aappublications.org at Nyu Medical Center on May 27, 2015
