2001 American Academy of Pediatrics Practice Parameter on Attention-Deficit/Hyperactivity Disorder
Alvin S. Yusin, MDChild Development Program; LAC + USC Medical Center; Women and Children’s Hospital; Los Angeles, CA 90033, USA
To the Editor.—
I appreciated the report of the Subcommittee on Attention-Deficit/Hyperactivity Disorder and Committee on Quality Improvement1 presented in the October 2001 issue of Pediatrics.
However, there was one concern that I did have when I read the committee’s recommendations.
There is a statement that "Unlike most other medications, stimulant dosages usually are not weight dependent."
That statement contradicts a study done by Sprague and Sleator,2 which suggests that doses of methylphenidate >1 mg/kg per day actually interfere with learning. If one major purpose of medication is to improve the learning capability of the child with attention-deficit/hyperactivity disorder in school, it would seem that going above that amount would be counterproductive.
Although I have not come across any papers that refuted the data generated by Sprague and Sleator, their study was done many years ago, and it is possible that I have not been diligent enough in searching for them. If such studies do exist, perhaps a committee member could provide me with the reference(s). If they do not exist, then it would seem to me that the recommendations regarding dosage should be reviewed and modified. The other option, I imagine, would be to do a new study on the effects on learning of the larger doses recommended by the committee.
REFERENCES
1. American Academy of Pediatrics. Subcommittee on Attention-Deficit/Hyperactivity Disorder and Committee on Quality Improvement. Clinical practice guideline: treatment of the school-aged child with attention-deficit/hyperactivity disorder.
Pediatrics.2001; 108
:1033
–1044
2. Sprague RL, Sleator EK. Methylphenidate in hyperkinetic children: differences in dose effects on learning and social behavior.
Science.1977; 198
:1274
–1276
James M. Perrin, MD
MassGeneral Hospital for Children; Harvard Medical School; Boston, MA 02114, USA
Mark Wolraich, MD
University of Oklahoma School of Medicine; Oklahoma City, OK 73104, USA
Martin Stein, MD
University of California at San Diego; La Jolla, CA 92093, USA
In Reply.—
Dr Yusin raises the question of whether the findings of Sprague and Sleator in their 1977 study1 indicate an important dose-related or weight-dependent response to methylphenidate or other stimulants, with higher doses interfering with improvements in learning. We appreciate his raising this interesting clinical question. What studies have been done in the past 25 years do not support this notion. The review by Solanto2 describes most of the subsequent studies and notes that they do not substantiate the study by Sprague and Sleator. This review also notes that effects on behavior, cognition, and complex learning may all require different doses. Recent studies covered in this review note that the potential narrowing of academic performance is at most a transient effect of stimulant treatment. The review additionally notes that no study has revealed that high doses impair academic performance in comparison to placebos. The work of Rapport et al3,4 also indicates that individual variations in response greatly outweigh the effects of weight. As the guidelines suggest, the best approach is to individualize treatment by starting at the lowest dose and titrating until one reaches optimal benefits with minimal side effects, develops significant side effects, or reaches the maximal allowable clinical dose.
REFERENCES
1. Sprague RL, Sleator EK. Methylphenidate in hyperkinetic children: differences in dose effects on learning and social behavior. Science.1977; 198 :1274 –1276
2. Solanto MV. Dose-response effects of Ritalin on cognitive self-regulation, learning and memory, and academic performance. In: Greenhill L, ed. Ritalin: Theory and Practice. 2nd ed. Larchmont, NY: Mary Ann Liebert, Inc; 2000:219–235
3. Rapport MD, Denney C, DuPaul GJ, Gardner MJ. Attention deficit disorder and methylphenidate: normalization rates, clinical effectiveness, and response prediction in 76 children. J Am Acad Child Adolesc Psychiatry.1994; 33 :882 –893[Web of Science][Medline]
4. Denney CB, Rapport MD. Predicting methylphenidate response in children with ADHD: theoretical, empirical, and conceptual models. J Am Acad Child Adolesc Psychiatry.1999; 38 :393 –401[CrossRef][Web of Science][Medline]
PEDIATRICS (ISSN 1098-4275). ©2004 by the American Academy of Pediatrics
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