Current concepts and controversies in the diagnosis and treatment of attention deficit hyperactivity disorder

Concerns about possible over-diagnosis and over-treatment of attention deficit hyperactivity disorder (ADHD) have been prominent in media reports, as have various competing claims about the safety and efficacy of the various treatments for ADHD. Drawing upon the results of the recent National Institutes of Health Consensus Conference, this paper reviews the evidence concerning these controversial areas. Although there do appear to be pockets of over-prescribing in selected communities, the best available evidence suggests that across the United States substantial underdiagnosis continues to occur, and only 50% of all children with ADHD are being treated with stimulant medications. Among those who are treated with stimulant medications, inadequate treatment is quite common. Substantial evidence suggests that for ADHD symptoms, stimulants are more effective than behavioral therapies in head-to-head comparisons. Combined medication and behavioral treatments do not offer any meaningful advantages over medication treatments alone for ADHD symptoms. For other areas of functioning, however (social skills, academic performance, etc.), combined treatments appear to offer some modest advantages over single treatment approaches. Although research findings show that ADHD can indeed be rigorously and reliably diagnosed under optimal conditions, and that carefully delivered treatments can yield substantial benefits, such best practices do not appear to be taking place in the real world. Thus, although the above controversies are facing some resolution in principal, in practice much remains to be done.