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ELECTRONIC ARTICLE:
Ronald T. Brown, Robert W. Amler, Wendy S. Freeman, James M. Perrin, Martin T. Stein, Heidi M. Feldman, Karen Pierce, Mark L. Wolraich and the Committee on Quality Improvement, Subcommittee on Attention-Deficit/Hyperactivity Disorder
Treatment of Attention-Deficit/Hyperactivity Disorder: Overview of the Evidence
Pediatrics 2005; 115: e749-e757 [Abstract] [Full text] [PDF]
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[Read P3R] Lack of empirical data for the treatment of up to half of the children with ADHD ignored
Joseph M. Rey   (10 July 2005)

Lack of empirical data for the treatment of up to half of the children with ADHD ignored 10 July 2005
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Joseph M. Rey,
Child and adolescent psychiatrist
University of Sydney, Sydney, Australia

Send letter to journal:
Re: Lack of empirical data for the treatment of up to half of the children with ADHD ignored

jmrey{at}bigpond.net.au Joseph M. Rey

Wolraich el al (1) in one of the first studies examining the impact of classification changes on the prevalence of ADHD already noted in 1996 that using DSM-IV criteria resulted in an increase of the prevalence of ADHD from 7.3% with DSM-IIIR to 11.4% with DSM-IV. While the prevalence of the combined type was 3.6% using DSM-IV, that of ADHD inattentive was 5.4% and hyperactive-impulsive 2.4%. More recent surveys have confirmed that a large proportion of participants with DSM-IV ADHD suffer from the inattentive or hyperactive-impulsive types (2,3). Regrettably, data supporting the validity of the subtypes of ADHD a decade after the publication of DSM-IV are still inconclussive (4). In addition, most of the treatment studies available include children with the combined type only –the MTA being the best example. Participants with other ADHD types are incorporated in recent studies, but results are consolidated for reporting. Although some trials describe a significant reduction in symptoms of inattention and hyperactivity-impulsivity in children with the combined type, it cannot be assumed that patients with ADHD inattentive or hyperactive-impulsive would obtain the same benefit until this is shown to be the case. For example, it is possible that children with hyperactive- impulsive ADHD may not benefit as much from medication, or that the optimal dosage required may vary according to type, or that they may respond better or worse than the combined type to psychosocial treatments (4). The conclusion is that the American Academy of Pediatrics (5) recommends the use of medication for children with the inattentive and hyperactive impulsive types of ADHD without empirical evidence. The implications have been emphasized already (6). Against this background, it is of concern that the overview of the treatment evidence (7), the American Academy of Pediatrics Guidelines (5) and Wolraich et al (8) fail to discuss these issues, nor do they highlight implications of the lack of empirical data for the management of up to half of the children diagnosed with ADHD.

References

1. Wolraich ML, Hannah JN, Pinnock TY et al. Comparison of diagnostic criteria for attention-deficit hyperactivity disorder in a county-wide sample. J Am Acad Child Adolesc Psychiatry 1996;35:319-324

2. Ford T, Goodman R, Meltzer H. The British child and adolescent mental health survey 1999: the prevalence of DSM-IV disorders. J Am Acad Child Adolesc Psychiatry 2003;42:1203-1211

3. Sawyer MG, Arney FM, Baghurst P et al. The mental health of young people in Australia: key findings from the child and adolescent component of the national survey of mental health and wellbeing. Aust N Z J Psychiatry 2001;35:806-814.

4. Woo BSC, Rey JM. The validity of the DSM-IV subtypes of attention- deficit/hyperactivity disorder. Aust N Z J Psychiatry 39:344–353; 2005

5. American Academy of Pediatrics, Committee on Quality Improvement, Subcommittee on Attention-Deficit/Hyperactivity Disorder. Clinical practice guideline: treatment of the school-aged child with attentiondeficit/hyperactivity disorder. Pediatrics. 2001;108:1033–1044

6. Rey JM, Sawyer MG. Are psycho-stimulants being used appropriately to treat child and adolescent disorders? Br J Psychiatry 2003;182:284-286

7. Brown RT, Amler RW, Freeman WS, Perrin, JM, Stein MT, Feldman HM, Pierce K, Mark L. Wolraich ML, and the Committee on Quality Improvement, Subcommittee on Attention-Deficit/Hyperactivity Disorder. Treatment of Attention-Deficit/Hyperactivity Disorder: Overview of the Evidence. American Academy of Pediatrics Technical Report. Pediatrics 2005;115;749- 757

8. Wolraich ML, Wibbelsman CJ, Brown TE, et al. Attention- Deficit/Hyperactivity Disorder among adolescents: A review of the diagnosis, treatment, and clinical implications. Pediatrics 2005;115:1734- 1746

Conflict of Interest:

The author was a member of the Australian Advisory Committee for Strattera (Ely Lilly) and Concerta (Janssen-Cilag) and was funded by Ely Lilly to attend an international conference.