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.
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