European Child & Adolescent Psychiatry | 2021
Minding the gap between clinical guidelines and real-life clinical work
Abstract
Today, we know that attention deficit/hyperactivity disorder (ADHD) is a lifelong disorder associated with impairments in multiple areas of functioning including school and learning, life skills, self-concept, social activities and risky behaviors [1]. The gold standard treatment for ADHD is multimodal, consisting both of medications, with stimulants being the first-line treatment, and psychosocial interventions [2–4]. Stimulants are very effective, resulting in substantial improvement of ADHD symptoms. In fact, stimulants are one of the most effective psychopharmacological therapies in psychiatry with an effect size of about 0.8. Nevertheless, long-term studies have shown a gap between the high efficacy of stimulants found in clinical trials, as also reported in clinical guidelines, and the less favorable long-term outcome of treatment reported in real clinical practice [5]. In this issue, Mücke et al. [6] report on the adherence of physicians and therapists to guidelines for the assessment and treatment of children and adolescents with ADHD in Germany. They found a gap between the utopia as presented in guidelines and the clinical practice in naturalistic settings. Moreover, they found that physicians follow clinical guidelines during initial assessment better than during follow-up visits. There are many challenges in the clinical treatment of ADHD, in the initiation, adherence, persistence, and optimization of treatment as we will describe below. Only about half of the children prescribed ADHD medications use the first prescription. Adherence to medications, defined in most studies as the number of days of medication supplied during a prespecified period, at the long run is very low. For example, in the MTA study, only 7% of individuals with ADHD consistently used medications at least 50% of days, at all intervals, along 15 years of follow-up [5]. Persistence to medications in ADHD seems to be another challenge. It is defined as the duration of time in which medication treatment is continued and is measured from initiation of treatment to discontinuation. Persistence was reported to be relatively short for ADHD medications, with a mean duration of about 3–6 months [7]. Various factors affect medication initiation, persistence and long-term adherence. Some are not subjected to change, such as sociodemographic status and age at treatment. Yet, there are important modifiable factors that can substantially improve treatment success including psychoeducation on ADHD and its treatment, optimized dose titration and follow-up of side effects and their management. These modifiable factors are addressed in major clinical guidelines for the assessment of ADHD and its treatment [2–4]. Guidelines are periodically updated and describe the gold standard recommendations for assessment, treatment and long-term follow-up of children, adolescents and adults with ADHD. They all highlight the importance of psychoeducation as the first intervention. The guidelines for psychoeducation recommendations are extremely informative and include information about symptoms of ADHD and the effect of ADHD on different life domains, effective modes of communication with the child and effective behavioral management of everyday routines. Some guidelines, such as The Canadian ADHD Resource Alliance (CADDRA [2]), recommend the use of questionnaires for the assessment of ADHD symptoms and suggest the use of functional impairment rating scales at baseline assessment as well as at follow-up visits; whereas other guidelines, such as the NICE [3] and the AAP [4] mention the use of rating scales for ADHD symptoms assessment only as optional. In this issue, Coghill et al. [1] demonstrate the heuristic value of including the well-established Weiss Functional Impairment Rating Scale-Parent Report as an outcome measure in phase 3 clinical trials of ADHD medications. This study shows that relying only on symptomatic scales * Livia Balan-Moshe [email protected]