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Effect of treatment modality on long-term outcomes in attention-deficit/hyperactivity disorder: a systematic review.

Arnold LE, Hodgkins P, Caci H, Kahle J, Young S - PLoS ONE (2015)

Bottom Line: Among significantly improved outcomes, the largest effect sizes were found for combination treatment.The greatest improvements were associated with academic, self-esteem, or social function outcomes.Older treatment initiation age or longer durations did not markedly affect proportion of improved outcomes reported, but measurement of outcomes long periods after treatment cessation may attenuate results.

View Article: PubMed Central - PubMed

Affiliation: Research Unit on Pediatric Psychopharmacology, The Ohio State University, Columbus, Ohio, United States of America.

ABSTRACT

Background: Evaluation of treatments for attention-deficit/hyperactivity disorder (ADHD) previously focused on symptom control, but attention has shifted to functional outcomes. The effect of different ADHD treatment periods and modalities (pharmacological, non-pharmacological, and combination) on long-term outcomes needs to be more comprehensively understood.

Methods: A systematic search of 12 literature databases using Cochrane's guidelines yielded 403 English-language peer-reviewed, primary studies reporting long-term outcomes (≥2 years). We evaluated relative effects of treatment modalities and durations and effect sizes of outcomes reported as statistically significantly improved with treatment.

Results: The highest proportion of improved outcomes was reported with combination treatment (83% of outcomes). Among significantly improved outcomes, the largest effect sizes were found for combination treatment. The greatest improvements were associated with academic, self-esteem, or social function outcomes. A majority of outcomes improved regardless of age of treatment initiation (60%-75%) or treatment duration (62%-72%). Studies with short treatment duration had shorter follow-up times (mean 3.2 years total study length) than those with longer treatment durations (mean 7.1 years total study length). Studies with follow-up times <3 years reported benefit with treatment for 93% of outcomes, whereas those with follow-up times ≥3 years reported treatment benefit for 57% of outcomes. Post-hoc analysis indicated that this result was related to the measurement of outcomes at longer periods (3.2 versus 0.4 years) after treatment cessation in studies with longer total study length.

Conclusions: While the majority of long-term outcomes of ADHD improve with all treatment modalities, the combination of pharmacological and non-pharmacological treatment was most consistently associated with improved long-term outcomes and large effect sizes. Older treatment initiation age or longer durations did not markedly affect proportion of improved outcomes reported, but measurement of outcomes long periods after treatment cessation may attenuate results.

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Flow diagram showing the selection process and results during the study screening process.
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pone.0116407.g001: Flow diagram showing the selection process and results during the study screening process.

Mentions: An extensive and systematic search was conducted of 12 literature databases to identify peer-reviewed, primary studies that reported long-term outcomes of individuals with ADHD. The databases were Academic Search Premier, CINAHL, Cochrane CRCT (including EMBASE), Criminal Justice Abstracts, ERIC, MEDLINE, Military & Government collection, NHS Economic Evaluation database, PsycARTICLES, PsycINFO, SocINDEX, and Teacher Reference Center. All 12 databases were searched in two search waves conducted in May 2010 and March 2011. A third search of 9 databases was conducted in March 2012. Three databases were not utilized in the third search (Academic Search Premier, NHS Economic Evaluation database, and PsycARTICLES) because no unique useful citations had been derived from those databases in the first searches. All other methods were held constant between the 3 search waves (see S1 Appendix for search string and limits). Search limits included English-language and publication date from January 1980 through December 2011 inclusive. Duplicates were eliminated electronically and manually. Based primarily on title and abstract, these studies were reviewed manually and inclusion was agreed on by two researchers. All disagreements between researchers on study inclusion were resolved by examining the full text of the study. Inclusion required that studies be published as peer-reviewed, primary research articles in the English language with full text available. Inclusion also required that the study had a comparator group (e.g., individuals with untreated ADHD) or a comparison measure (e.g., pre-treatment baseline), and that ADHD was a primary disorder under study. Treatments included pharmacological, non-pharmacological, or combination treatments/interventions intended for treatment of ADHD. Only studies reporting long-term outcomes of 2 years or more (follow-up time, not necessarily treatment duration) were included. The 2-year long-term outcome criterion could be met by longitudinal studies with prospective follow-up measurements ≥2 years, retrospective studies with a time period ≥2 years, cross-sectional studies comparing two ages differing by 2 years or more, or cross-sectional studies of individuals age 10 years or older. Age 10 was chosen as the minimum age for single-age, cross-sectional studies, based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) diagnosis criteria that symptoms be present before age 7 years, thus conservatively allowing at least 2 years to pass before outcomes were measured. Meta-analyses, case studies, and literature reviews were excluded. A checklist of Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) is provided in S2 Appendix and a PRISMA flow diagram of the study selection process [22] is provided in Fig. 1.


Effect of treatment modality on long-term outcomes in attention-deficit/hyperactivity disorder: a systematic review.

Arnold LE, Hodgkins P, Caci H, Kahle J, Young S - PLoS ONE (2015)

Flow diagram showing the selection process and results during the study screening process.
© Copyright Policy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4340791&req=5

pone.0116407.g001: Flow diagram showing the selection process and results during the study screening process.
Mentions: An extensive and systematic search was conducted of 12 literature databases to identify peer-reviewed, primary studies that reported long-term outcomes of individuals with ADHD. The databases were Academic Search Premier, CINAHL, Cochrane CRCT (including EMBASE), Criminal Justice Abstracts, ERIC, MEDLINE, Military & Government collection, NHS Economic Evaluation database, PsycARTICLES, PsycINFO, SocINDEX, and Teacher Reference Center. All 12 databases were searched in two search waves conducted in May 2010 and March 2011. A third search of 9 databases was conducted in March 2012. Three databases were not utilized in the third search (Academic Search Premier, NHS Economic Evaluation database, and PsycARTICLES) because no unique useful citations had been derived from those databases in the first searches. All other methods were held constant between the 3 search waves (see S1 Appendix for search string and limits). Search limits included English-language and publication date from January 1980 through December 2011 inclusive. Duplicates were eliminated electronically and manually. Based primarily on title and abstract, these studies were reviewed manually and inclusion was agreed on by two researchers. All disagreements between researchers on study inclusion were resolved by examining the full text of the study. Inclusion required that studies be published as peer-reviewed, primary research articles in the English language with full text available. Inclusion also required that the study had a comparator group (e.g., individuals with untreated ADHD) or a comparison measure (e.g., pre-treatment baseline), and that ADHD was a primary disorder under study. Treatments included pharmacological, non-pharmacological, or combination treatments/interventions intended for treatment of ADHD. Only studies reporting long-term outcomes of 2 years or more (follow-up time, not necessarily treatment duration) were included. The 2-year long-term outcome criterion could be met by longitudinal studies with prospective follow-up measurements ≥2 years, retrospective studies with a time period ≥2 years, cross-sectional studies comparing two ages differing by 2 years or more, or cross-sectional studies of individuals age 10 years or older. Age 10 was chosen as the minimum age for single-age, cross-sectional studies, based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) diagnosis criteria that symptoms be present before age 7 years, thus conservatively allowing at least 2 years to pass before outcomes were measured. Meta-analyses, case studies, and literature reviews were excluded. A checklist of Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) is provided in S2 Appendix and a PRISMA flow diagram of the study selection process [22] is provided in Fig. 1.

Bottom Line: Among significantly improved outcomes, the largest effect sizes were found for combination treatment.The greatest improvements were associated with academic, self-esteem, or social function outcomes.Older treatment initiation age or longer durations did not markedly affect proportion of improved outcomes reported, but measurement of outcomes long periods after treatment cessation may attenuate results.

View Article: PubMed Central - PubMed

Affiliation: Research Unit on Pediatric Psychopharmacology, The Ohio State University, Columbus, Ohio, United States of America.

ABSTRACT

Background: Evaluation of treatments for attention-deficit/hyperactivity disorder (ADHD) previously focused on symptom control, but attention has shifted to functional outcomes. The effect of different ADHD treatment periods and modalities (pharmacological, non-pharmacological, and combination) on long-term outcomes needs to be more comprehensively understood.

Methods: A systematic search of 12 literature databases using Cochrane's guidelines yielded 403 English-language peer-reviewed, primary studies reporting long-term outcomes (≥2 years). We evaluated relative effects of treatment modalities and durations and effect sizes of outcomes reported as statistically significantly improved with treatment.

Results: The highest proportion of improved outcomes was reported with combination treatment (83% of outcomes). Among significantly improved outcomes, the largest effect sizes were found for combination treatment. The greatest improvements were associated with academic, self-esteem, or social function outcomes. A majority of outcomes improved regardless of age of treatment initiation (60%-75%) or treatment duration (62%-72%). Studies with short treatment duration had shorter follow-up times (mean 3.2 years total study length) than those with longer treatment durations (mean 7.1 years total study length). Studies with follow-up times <3 years reported benefit with treatment for 93% of outcomes, whereas those with follow-up times ≥3 years reported treatment benefit for 57% of outcomes. Post-hoc analysis indicated that this result was related to the measurement of outcomes at longer periods (3.2 versus 0.4 years) after treatment cessation in studies with longer total study length.

Conclusions: While the majority of long-term outcomes of ADHD improve with all treatment modalities, the combination of pharmacological and non-pharmacological treatment was most consistently associated with improved long-term outcomes and large effect sizes. Older treatment initiation age or longer durations did not markedly affect proportion of improved outcomes reported, but measurement of outcomes long periods after treatment cessation may attenuate results.

Show MeSH
Related in: MedlinePlus