ADHD: Overdiagnosed and overtreated, or misdiagnosed and mistreated?
ABSTRACT
In today’s changing medical climate, physicians need to treat attention-deficit/hyperactivity disorder (ADHD) better and more cost-effectively. The authors review recommendations supported by recent research and offer simple practices that integrate medicine and behavioral health for patients with ADHD.
KEY POINTS
- Despite concerns about overdiagnosis and overtreatment, many children and youth diagnosed with ADHD still receive no treatment or insufficient treatment.
- Today, more children are prescribed drug therapy when ADHD is diagnosed, but the initial titration of medication is often done without sufficient physician supervision.
- ADHD symptoms improve with drug therapy, but improvement is inconsistently sustained due to poor treatment adherence.
- Drug therapy and behavioral therapy work together. Outcomes can be determined by measuring both improved behaviors and reduced symptoms.
Integrate behavioral therapy
Given the evidence that behavioral intervention enhances drug therapy,50 behavioral therapy should be integrated with drug therapy to create an inclusive context for change. Behavioral therapy is delivered in a variety of ways including individual and group parent training, home management consultation, daily school report cards, behavioral coaching, classroom behavior management, and peer interventions. Behavioral intervention enhances stimulant effectiveness51 to improve compliance, on-task behavior, academic performance, social relationships and family functioning.52
Behavioral therapy is now generally included in health insurance coverage. In addition, many clinics now offer shared medical appointments that combine close monitoring of drug therapy with behavioral coaching to small groups of parents in order to manage symptoms of ADHD at a minimal cost.
Measure outcomes
Measuring outcomes of ADHD treatment over time improves care. The primary care physician may use electronic medical record data management to track a patient’s progress related to ADHD features. The Clinical Global Improvement scale is a 7-point assessment that is easily done by parents and the physician at well visits and is ubiquitous in ADHD clinical trials.53 Change over time indicates when to suggest changes in treatment.
Finally, clinicians can demonstrate that appropriate, comprehensive care does not simply relieve ADHD symptoms, but also promotes quality of life. Healthcare providers can guide parents to improve existing abilities in children rather than leave parents with the notion that something is wrong with their child.
For example, research suggests that some patients with ADHD show enhanced creativity54,55; cognitive profiles with abilities in logical thinking, reasoning, and common sense56; and the capacity for intense focus in areas of interest.57 Some authors have even speculated that historical figures such as Thomas Edison and Albert Einstein would have been diagnosed with ADHD by today’s standards.58
MEETING THE DEMANDS OF AFFORDABLE CARE
Many children and youth diagnosed with ADHD still receive no or insufficient pharmacotherapy and behavioral therapy. More than one-third of children reported by their parents as not receiving treatment were also reported to have moderate or severe ADHD.59,60
At the same time, though more children today are being prescribed pharmacotherapy when ADHD is diagnosed, physician involvement is often limited during titration,7 and treatment usually consists of reducing symptoms without increasing adaptive behaviors with behavioral therapy.45 In addition, even though ADHD symptoms initially improve with pharmacotherapy, improvement is not sustained because of poor adherence.
The healthcare costs of ADHD are high because impairment extends beyond the patient to disrupt family life and even the workplace, as parents take time off to manage children. Because of uncertain costs of quality treatment, the best-practice treatment option for ADHD—ie, combined behavioral therapy and medicine—is increasingly accessible but still not as widely accessible as medication treatment. The value of care improves slowly while the number of patients continues to increase. However, caregivers have the opportunity to add value to the treatment of ADHD.
When we improve medication management, improve adherence to treatment, combine behavioral therapy and pharmacotherapy, consistently measure outcomes, and recognize positive traits of ADHD in our patients, we may turn the demands of affordable care into a breakthrough for many who live with the condition.
Acknowledgment: The authors wish to thank Ralph D’Alessio, BA, for his services in reference review and for his conscientious participation in the Cleveland Clinic Medication Monitoring Clinic, ADHD Center for Evaluation and Treatment.
