An auditable protocol for treating attention deficit/hyperactivity disorder

Abstract:

We present an auditable protocol for attention deficit/hyperactivity disorder (ADHD) or hyperkinetic disorder. The protocol is derived from standard recommendations and evidence, and is intended for outpatient medical clinic practice in secondary care. Suggested side effect rating scales are included.

FAB RESEARCH COMMENT

These authors are acknowledged experts in this field, and this paper provides an overview of the systematic, evidence-based approach that they propose for the clinical management of ADHD.

The following text is taken from their introduction. It includes an explicit comment on evidence-based dietary approaches which is highlighted here in bold type, but please note that this added emphasis is ours.

This attempt at a protocol builds on apparent consensus among clinical scientists internationally that the following issues have to be taken into account.

• A large proportion of disruptive and disorganised children presenting to health services will fulfil diagnostic criteria for ADHD
• Among such children there will be extensive co-morbidity
• There will also be a high rate of educational failure
• Treatment effects have been shown for psychological interventions, dietary manipulation, and medication
• There are a number of treatment interventions for which there is little or no evidence for effect, or evidence for a lack of effect when compared with placebo.

Although medication is the most powerful treatment in terms of effect size, not all cases will need it, not all families will accept it, and not all children will be suitable for it.

Psychological intervention may prove sufficient.

If it is not, there is evidence for the effectiveness of an individually constructed elimination diet. This is based on the principle of cutting out all foods apart from a very small number, testing for the effect of this, and if a positive effect is found, adding further foods singly and gradually, observing for adverse reactions. Foods so identified will then be removed from the child's eventual diet.

This is the "few foods" approach to constructing an elimination diet. We do not think there is adequate evidence for other diets such as the Feingold or gluten free diets, or those which include supplementation of certain fats, megavitamins, or herbs.

There is no firm scientific evidence for the effectiveness on core ADHD symptoms of homeopathy, psychoanalytic psychotherapy, naturopathy, or cranial osteopathy, though we are aware of individuals, parents, and professionals, who express enthusiasm for one or the other. Accordingly we have actively excluded such interventions from our approach.

The position of family therapy and cognitive therapy is less clear. Effects of each can be shown on selected aspects of ADHD in individual children, but the effects are partial or unpredictable. We consider them to be supplementary interventions rather than core components, the indications for which are not yet established. Accordingly we have not included them either.

We have omitted consideration of classroom management techniques because these are best implemented by educational rather than health service professionals. They have been shown to be effective and need to be deployed as a component of treatment. This makes the point that our suggestion is specifically about the contribution of the Health Service within a desirable multimodal, multiagency approach.

We assume that, where psychological intervention is insufficient in alleviating symptoms and promoting academic and social progress, a trial of medication will be indicated. There are preconditions to be met for this to be carried out. Although none are absolute, if any are not present we consider it wise to obtain a second opinion from a knowledgeable colleague before proceeding.

Our general approach is to indicate what should be done for adequate management. We have prepared lists which include boxes against items so that these can be ticked when the task is completed. This means that the protocol can assist self monitoring as well as potentially being subject to audit in a quality assurance programme.