A new report from the U.S. Department of Health and Human Services’ Agency for Healthcare Research and Quality (AHRQ) shows that formal training in parenting strategies is a low-risk, effective method for improving preschool-aged children’s behavior who are at risk for developing attention deficit hyperactivity disorder (ADHD), whereas using medication for children below the age of 6 years shows less evidence.

The report, entitled “Attention Deficit Hyperactivity Disorder: Effectiveness of Treatment in At-Risk Preschoolers; Long-Term Effectiveness in All Ages; and Variability in Prevalence, Diagnosis, and Treatment,” is a comparative effectiveness review devised for AHRQ’s Effective Health Care Program by the McMaster Evidence-based Practice Center in Hamilton, Ontario, Canada.

According to the report, strong evidence supports the effectiveness of formal parenting interventions, also called parent behavior training or PBT, for children below the age of 6 years. The interventions are free of complication and not harmful, but parents who drop out of the therapy program jeopardize successful results.

The report also found that methylphenidate (Ritalin) and atomoxetine (Strattera) to treat ADHD symptoms are generally safe and effective for improving behavior in children above the age of 6 years, although few studies have been conducted regarding their effects beyond 12 to 24 months. There is also little knowledge about the long-term effects of other medications for this condition.

AHRQ Director Carolyn M. Clancy, M.D. said:

“ADHD can place many challenges on families with young and school-age children. This new report and these summary publications will help children, parents and their doctors work together to find the best treatment option based on the family’s values, preferences and needs.”

ADHD, is characterized by children’s inattention, hyperactivity and impulsivity and is most frequently recognized and treated in primary school. According to estimation, about 5% of children worldwide display behavior consistent with ADHD, with boys tending to be twice as likely to be diagnosed with ADHD than girls. Identifying and managing ADHD can be very challenging, and depending on culture and geography there is a wide array of diagnosis and treatment strategies. Numerous preschool-age children with aggressive or noncompliant behavior who may eventually develop ADHD are initially diagnosed with generally disruptive behavior disorder. Since Ritalin was introduced in the 1950s for the treatment of disruptive behavior, drug-based treatments have risen and scientists now have a better understanding of ADHD as a disorder and are better at identifying it.

Annual prescriptions for Ritalin have risen to about 11 million by 1999, with an additional 6 million prescriptions for amphetamines. The uncertainty continues whether ADHD diagnoses are accurate and potential over-prescription of Ritalin and other drugs, especially in recent years with drug treatments spreading to other populations. Over the past 25 years, four major PBT strategies have been developed, designed to assist parents in managing their child’s problem behavior with more effective disciplinary actions. This involves using rewards and no punishment consequences that increase positive and caring relationships between parents and their child, and aims to improve both child behavior and parenting skills.

According to the AHRQ report, these PBT interventions have proven to be effective and without any reported risk of complications for preschool-age children with disruptive behavior disorder and those with ADHD. The report shows that for older children methylphenidate and atomoxetine are effective in controlling ADHD symptoms without substantial risk of harms for up to 2 years, however, there is still little knowledge about the longer-term effectiveness and possible adverse effects.

The report is the latest comparative effectiveness review from AHRQ’s Effective Health Care Program, which assists doctors, nurses, patients, pharmacists and others in selecting the most effective therapies by sponsoring development of evidence reports and technology assessments to support public- and private-sector organizations in their attempts to improve the quality of health care in the U.S.

Written by Petra Rattue