BMJ  2004;329:908-909 (16 October), doi:10.1136/bmj.329.7471.908

Education and debate

Use of stimulants for attention deficit hyperactivity disorder

AGAINST

¹ Honeysuckle House, Balscote OX15 6JW h.marcovitch{at}btinternet.com

Definitive diagnosis of attention deficit hyperactivity disorder is complex. David Coghill believes the condition is undertreated, but Harvey Markovitch argues that current uncertainties about diagnosis and treatment mean doctors should be cautious

Introduction

Doctors must take great care before prescribing psychoactive drugs for children. Relying on published trials and manufacturers' summaries of product characteristics (data sheets) has proved inadequate for selective serotonin reuptake inhibitors.¹ Doctors should be just as cautious before prescribing central nervous system stimulants for attention deficit hyperactivity disorder (ADHD) and consider their response to the fact that despite decades of use, the first reasonably large medium term controlled trial (14 months' use) was not published until 1999.²

Even though evidence of safety and efficacy is more qualitative than quantitative, overall prevalence of stimulant use may be as high as 6% in the United States. If we were to follow the American Academy of Pediatrics guidelines on treating school aged children with ADHD,³ as many as 17% of all children would be treated.⁴ Putting this alongside the National Institute for Clinical Excellence's recommendation that about 1% of UK children probably merit stimulants⁵ raises questions.

Problems of diagnosis

Firstly, diagnostic criteria for the disorder differ widely. Some of the disparate figures mentioned above are explained by case series using either the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R or DSM-IV) or the International Classification of Diseases (ICD-10) for diagnosis.

Secondly, I contend that it is unlikely that most prescribers go through the extensive initial and follow up checklists recommended when starting and maintaining children on stimulants.⁶ These include separate child and parental interviews, completion of a validated rating scale by parents and a teacher, and a teacher's report. Prescribers must check symptoms against one of the standard diagnostic lists and also check the child's social functioning and whether he or she has any comorbidity, such as depression. All of this is completed before the stimulant is given. In addition, parents should be taught handling skills and simple behavioural techniques. Parental and teacher ratings and reports of possible adverse effects should be repeated monthly for six months to inform dose titration.

There is no reason to disbelieve that specialist academic units, such as the one from which Hill and Taylor report,⁶ proceed with such thoroughness and care. It would be asking too much to believe that all paediatricians, child psychiatrists, and general practitioners follow suit, even if they had the time available to do so. Indeed, there is some evidence for this contention, at least in Australia and the United States. Rey and Sawyer looked at published surveys of community samples of children with ADHD or taking stimulants and concluded that 17.5-66% of participants taking stimulants did not have ADHD (and 12.1-86.7% of those with ADHD were being treated).⁴

Caution is needed

Evidence exists that stimulants are mostly safe and often effective. What is lacking is evidence that the right children are being treated. While there is so much disagreement about prevalence, confusion about how to distinguish ADHD from conduct disorders, and inconsistent guidelines, prescribers should tread warily. Paediatrics, like other specialties, is full of ideas that seemed good at the time. We have (I hope) stopped prescribing antihistamines to treat crying and sleeplessness in small infants, even though this was standard practice in the past. Cisapride was abandoned in haste, when its potential cardiac ill effects were defined, despite having been used extensively in treating children and even premature babies with gastrooesophageal reflux. Most selective serotonin reuptake inhibitors are no longer recommended for children. If we do not take care, methylphenidate might meet a similar fate, even though it clearly benefits some children and their families.—Harvey Marcovitch

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Contributors and sources: Harvey Marcovitch was a practising paediatrician for 25 years so was faced with many such children. Lack of resources meant that few had the luxury of a referral to child and adolescent mental health services. As press officer for the Royal College of Paediatrics and Child Health he has had to field constant, sometimes hostile, media inquiries and so has had to make himself familiar with the scientific literature on the subject.

Competing interests: HM is employed by BMJ Publishing Group but is unaware of any advantage to him of being invited to submit this paper. He once received a small fee for contributing to a debate on this subject.

References

1. Jureidini JN, Doecke CJ, Mansfield PR, Haby MM, Menkes DB, Tonkin AL. Efficacy and safety of antidepressants for children and adolescents BMJ 2004;328: 879-83.[Free Full Text]
2. MTA Cooperative Group. A 14-month randomised clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. Arch Gen Psychiatry 1999;56: 1073-86.[Abstract/Free Full Text]
3. American Academy of Pediatrics. Clinical practice guideline: treatment of the school aged child with attention-deficit/hyperactivity disorder. Pediatr 2001;108: 1033-44.[Abstract/Free Full Text]
4. Rey JM, Sawyer MG. Are psychostimulant drugs being used appropriately to treat child and adolescent disorders? Br J Psychiatr 2003;182: 284-6.[Free Full Text]
5. National Institute for Clinical Excellence. Guidance on the use of methylphenidate for attention deficit/hyperactivity disorder (ADHD) in childhood. Technology appraisal guideline No 13. www.nice.org.uk/page.aspx?o=11652 (accessed 15 Sep 2004).
6. Hill P, Taylor E. An auditable protocol for treating attention deficit/hyperactivity disorder. Arch Dis Child 2001;84: 404-9.[Abstract/Free Full Text]

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