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BMJ No 7113 Volume 315 Editorial Saturday 11 October 1997
Attention deficit hyperactivity disorderThere is no easy answer on whether to medicate or notA syndrome that was described by the ancient Greeks and has been widely observed by physicians since then is likely to have considerable face validity, but there continues to be disagreement about the diagnosis, cause, prevalence, and treatment of attention deficit hyperactivity disorder.(1) From the beginning of this century the concept of the condition has evolved from it being a biologically based disorder of behaviour control, from a condition with minimal brain dysfunction, to a disorder characterised by a deficit of attention.(2) The main controversy now is about how to treat the condition. The past 20 years have seen the development of diagnostic criteria in both Britain and America. In 1981 the criteria of the Diagnostic and Statistical Manual version III (DSM-III) departed from those of the International Classification of Diseases ninth edition (ICD-9) in creating subtypes of attention deficit disorder with and without hyperactivity. Meanwhile, the ICD-9 continued to emphasise "pervasive hyperactivity" as the hallmark of the so called hyperactive syndrome. Now, however, DSM-IV and ICD-10 research criteria for attention deficit hyperactivity disorder and hyperkinetic disorder are almost identical, showing a rapprochement between American and British approaches. Theories of aetiology have also evolved, influenced by advances in brain imaging. The current view is that there is dysfunction of prefrontal and subcortical striatal areas of the brain that are implicated in inhibition of irrelevant responses and executive functions.(3) Twin studies suggest high heritability of the disorder,(4) while a recent molecular genetic study suggests a possible relation with the D4 receptor gene.(5) Important questions remain about the relation of the disorder to language and learning disability at the phenotypic and genetic level; and the phenotype may have broadened to include children with learning disability. Approaches to treatment have also progressed. An important advance was the use of systematic behaviour modification techniques in the management of disruptive classroom behaviour.(6) In America and Australia, however, management has been characterised by an increasing use of stimulant medications such as methylphenidate and dexamphetamine, with 3-5% of primary schoolchildren treated in some American states. Many studies have shown positive effects of stimulant medication in most children diagnosed with attention deficit hyperactivity disorder.(7-8) Concerns about addiction have not proved justified, and if the drugs are properly prescribed side effects are not a major concern, although morbidity in terms of appetite, dysphoria, headache, and tics should be carefully monitored.(9) Public concern about overuse of medications has alternated with increasing parental demands for treatment for the disorder. The apparent differences in the use of stimulant drugs between Europe and America have been commented on, but differences of similar magnitude exist within countries, certainly within America and Australia.(10-11) Many clinicians in both Britain and America have remained committed to environmental explanations of behaviour and have been loath to use drugs. Additionally, disputes over whether attention deficit hyperactivity disorder is a specific abnormality or merely the extreme end of a range of behaviour have clouded the issue. Nevertheless, when DSM-IV or ICD-10 criteria are used for case selection, significant numbers of the school aged population benefit from careful use of stimulant drugs. Use of these drugs improves not only school performance but often family and social functioning as well.(12) A recent report from Michigan shows that the percentage of boys aged 10-11 years being treated with stimulant drugs was 3-5%, with considerable variation between counties.(11) Primary care physicians wrote 84% of prescriptions, while paediatricians wrote 59% of prescriptions for patients younger than 20 years. A similar report from Australia indicates a significant increase in stimulant use between 1988 and 1993, with wide variation between states and territories.(10) These data suggest that these paediatricians and primary care physicians have taken a pragmatic approach, tending to fill the void left by their more cautious mental health colleagues. Nevertheless, the widespread use of drugs for this condition by paediatricians, and in some places by general practitioners, raises questions about whether they are adequately aware of, or trained in, behavioural therapies or, indeed, in pharmacotherapy. The role of general practitioners should be more clearly defined in screening for attention deficit hyperactivity disorder. The DSM-IV or ICD-10 based screening instruments should be made available for use by general practitioners. In Australia the National Health and Medical Research Council has produced a useful working party report on the condition, which establishes a multidisciplinary policy. The draft report emphasises the use of appropriate rating scales, as well as multiple sources of information including parents, caregivers, professionals, and especially teachers.(13) The promise of advances from genetic and brain imaging methods will require a continued and expanded multidisciplinary effort. Meanwhile, whether to treat the condition with drugs will be determined by the complex interactions of cultural norms, medical manpower, and parental expectations. Florence Levy Senior staff specialist
Prince of Wales Hospital, References 1 Husain S A, Cantwell D P. Fundamentals of child and adolescent psychiatry. Washington, DC: American Psychiatric Press, 1991. 2 Douglas V I. Stop, look and listen: the problem of sustained attention and impulse control in hyperactive and normal children. Can J Behav Sci 1972;4:259-82. 3 Castellanos F X, Giedd J N, Marsh W L. Quantitative brain magnetic resonance imaging in attention deficit hyperactivity disorder. Arch Gen Psychiatry 1996;53:607-16. 4 Levy F, Hay D, McStephen M, Wood C, Waldman I. Attention deficit hyperactivity disorder: a category or a continuum? Genetic analysis of a largescale twin study. J Am Acad Child Adolesc Psychiatry 1997;36:737-4. 5 La Hoste G J, Swanson J M, Wigal S B, Globe C, Wigal T, King N, et al. Dopamine D4 receptor gene is associated with attention deficit hyperactivity disorder. Molecular Psychiatry 1996;1:121-4. 6 O'Leary K D, Pelham W E, Rosenbaum A, Price G H. Behavioural treatment of hyperkinetic children: an experimental evaluation of its usefulness. Clin Pediatrics 1996;15:510-5. 7 Barkley R A. A review of stimulant drug research with hyperactive children. Journal of Child Psychology and Psychiatry 1977;18:137-65. 8 Elia J, Borcherding B G, Rapoport J L. Methylphenidate and dextroamphetamine treatments of hyperactivity: are there true non-responders? Psych Res 1991;36:141-55. 9 Barkley R A, McMurray M B, Edelbrook C S, Robbins K. Side effects of methylphenidate in children with attention deficit hyperactivity disorder: a systematic placebo-controlled evaluation. Pediatrics 1990;86:184-92. 10 Valentine J, Zubrick S, Sly P. National trends in the use of stimulant medication for attention deficit hyperactivity disorder. J Paediatr Child Health 1996;32:223-7. 11 Rappley M D, Gardiner J C, Jetton J R, Houng R T. The use of methylphenidate in Michigan. Arch Pediatr Adolesc Med 1995;149:675-9. 12 Barkley R A, Cunningham C E. The effects of methylphenidate on the mother-child interactions of hyperactive children. Arch Gen Psychiatry 1979;36:201-8. 13 Australian National Health and Medical Research Council. Report of working party on ADHD. Canberra: Australian Government Publishing Service, 1996.
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