Pelham and colleagues are to be lauded on their elegant work
elucidating some of the common beliefs and assumptions regarding the
treatment of ADHD with two of the most commonly used drugs.
Four questions/comments:
1) Were you aware, forewarned, and/or disappointed that your critical work
on such a germaine, important topic for the general pediatrician was being
relegated to printed abstract status?
2) Did your subjects include any who were solely ADHD-inattentive
form? Our experience has been that the majority of these inattentive
children require about 1/2 the standard dosing of the hyperactive
children, and that a single dose of amphetamine-products is often
sufficient to cover them pharmacologically for the entire day.
3) Perhaps the reason that the study children only required a single
dose (vis a vis the Swanson study) of Adderall to obtain reasonably good
responses is that they were NOT in a classroom setting, which is
inherently boring, has double the number of distractions (30 pupils), and
requires sitting in a single seat for a much more prolonged period of
time. Further, leisure activities (outdoor sports) comprised the majority
of the day for your study patients. They were able to move from one locale
to another.
In contrast, daily routine classroom activities and studies require
tremendously more mental effort and struggles for these children with
ADHD. More pronounced medication effects and differences possibly are more
likely to be seen when ennui is frequent and mental challenges are
constantly required. Possibly the Swanson study was conducted within a
more typical classroom setting. Personally we have experienced that
teachers usually complain that Adderall as a single dose "wears off" soon
after lunch in the majority of our truly hyperactive-ADHD patients. Thus
we most frequently prescribe a second half-dose of Adderall (or dexedrine
spansules) at lunch in the very hyperactive child. Waiting for an
afterschool dose would be intolerable in a typical demanding classroom
setting for many of these children. The setting could explain why your
patients performed so well with the lower range dose (0.3 to 0.6
mg/kg/dose) of MPH.
Also, hasn't an earlier study shown that a higher dose of stimulant
medication is required to improve hyperactivity compared with
distractibility.
4) I was glad to see that you primarily used teacher rating scales,
as opposed to clinician global impression (CGI), to document medication
response. It is alarming that newer pharmacologic trials of ADHD
medications are relying solely on the physician observer and, in part, on
parental questionaire to ascertain drug efficacy. Neither set of observers
witness the child during intervals when concentration and sitting still is
required, ie, the classroom.
Keep up the excellent, practical scientific work on such an important
integral problem encountered by the general pediatrican.
Best regards
SLB
eLetters: ![[Read eLetters]](/icons/misc/sectionDOWN.gif){kind=icon}
