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Attention-deficit/hyperactivity disorder: are we helping or harming?

BMJ 2013; 347 doi: (Published 05 November 2013) Cite this as: BMJ 2013;347:f6172

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Re: Attention-deficit/hyperactivity disorder: are we helping or harming?

Thomas’s analysis focused extensively on different issues concerning the overdiagnosis and overtreatment of ADHD, and concluded that “the overdiagnosis of ADHD resides within the clinical subjectivity of impairment” [1].

We argue that the core issue lies in the fact that there are two different steps in which clinicians are required to quantify the impairment level. The first concerns the evaluation of symptom severity as part of the diagnostic path; the second concerns a global functioning severity assessment before deciding for a pharmacological intervention. Overtreatment could therefore depend not only on the diagnosis, but also on the assessment of the ADHD impairment severity when the disorder has already been diagnosed.

According to the new Diagnostic and Statistical Manual of Mental Disorders (DSM), clinicians should distinguish the severity of symptoms and functional impairment between mild, moderate, and severe [2]. As pointed out by McClure in a recent editorial, the evidence-based recommendations from NICE were that the pharmacological treatment be considered in cases of “severe” ADHD [3]. Thus the following is questionable: is the rising trend of stimulant prescriptions related to an increase in “severe” ADHD prevalence, even though NICE reports a stable 1% [4], or is it rather related to an inadequate assessment?

In clinical practice, the clinicians’ subjectivity is often intrinsic to the psychiatric area and plays a role not only in mental health diagnosis [5], but also in the wide variation in prescription rates by country, region, and even within the same city [6]. In the ADHD context, as Thomas and coll. pointed out, practice guidelines only suggest that a medical, psychosocial, and developmental evaluation should be carried out to define ADHD severity, leaving it up to individual clinicians to rate this impairment. Unfortunately, the categorical or dimensional types of classifications (such as mild, moderate, and severe) are more academic attitudes than useful approaches in/for the practice.

As in the Wolverhampton experience,[7] different initiatives were set up in local settings to oversee the implementation of the guidelines, but only a more systematic, shared, and widespread (national) approach can prevent (or reduce the risk of) the harms of overdiagnosis and disease mongering.

In June 2011, following a previous, national drug oriented registry set up in 2007 [8-9], an official regional registry was activated in the Lombardy Region in an attempt to limit the problems outlined above, guaranteeing appropriate ADHD management to each child and adolescent from the moment the disorder is first suspected or reported. In practice, a strict diagnostic assessment of the disorder prior to treatment, as well as its systematic monitoring during treatment, must be guaranteed by each of 18 local reference centres accredited by the regional health authorities.

An “Assessment Group” was established within the register’s Working Group, consisting of a clinician from each centre and a group of researchers at the Coordinating Centre (IRCCS-Istituto di Ricerche Farmacologiche “Mario Negri”). The aim of this group was to define a complete, evidence-based, shared assessment pathway for all children and adolescents aged 5–17 years who accessed any of the 18 reference centres for a suspected ADHD diagnosis. This pathway, consisting of 6 mandatory steps, including the Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS) for a complete psychopathology overview and the Clinical Global Impressions scale for Severity (CGI-S) and Children's Global Assessment Scale (C-GAS) to quantify symptoms and global functioning severity, respectively, was agreed, approved, and shared (sometimes laboriously) by all centres. Moreover, because of the great concern about both safety and overuse of drugs and overdiagnosis in ADHD, the Coordinating Centre organises training sessions and discussion meetings for the reference centres’ clinicians. Further educational events are also provided for community pediatricians, families, and other health professionals to diffuse more comprehensive knowledge on ADHD that is based on recent, evidence-based practice and European guidelines.

In such a context, the prevalence rate of ADHD was stable at around 0.5‰ in the 6-17 year old population, and, from 2011 to 2012, the rate of drug users among children and adolescents with ADHD decreased from 24 to 16%. This trend is different from other Italian regions, and from other European countries and the US, where ADHD overdiagnosis and overtreatment had already started with the previous editions of the DSM. Thus, the message to be learnt from the Lombardy Region’s registry is that “limiting overdiagnosis and disease mongering is possible!” if adequate resources are available, appropriate training initiatives are taken, and patients’ interests in care guide the decisions (even those concerning the manual classifications).

1. Thomas R, Mitchell GK, Batstra L. Attention-deficit/hyperactivity disorder: are we helping or harming? BMJ 2013;347:f6172–2.
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorder, Fifth Edition. American Psychiatric Publishing ed., Washington DC, 2013.
3. McClure I. Prescribing methylphenidate for moderate ADHD. BMJ 2013;347:f6216–6.
4. National Institute for Health and Care Excellence. Attention deficit hyperactivity disorder.
CG72. 2008.
5. Jackson T. Attention, please. BMJ 2013;347:f6697
6. Arango C. To treat or not to treat? and How to treat? Two questions whose answers are far removed from evidence informed practice in child psychiatry. Eur Child Adolesc Psychiatry. 2013 Sep;22(9):521-2. doi: 10.1007/s00787-013-0457-z.
8. Panei P, Arcieri R, Vella S, Bonati M, Martini N, Zuddas A. Italian attention-deficit/hyperactivity disorder registry. Pediatrics. 2004 Aug;114(2):514.
9. Didoni A, Sequi M, Panei P, Bonati M; Lombardy ADHD Registry Group. One-year prospective follow-up of pharmacological treatment in children with attention-deficit/hyperactivity disorder.
Eur J Clin Pharmacol. 2011 Oct;67(10):1061-7. doi: 10.1007/s00228-011-1050-3.

Competing interests: No competing interests

26 November 2013
Maurizio Bonati
Head, Department of Public Health
Laura Reale
IRCCS - "Mario Negri" Pharmacological Research Institute
Via G. La Masa 19, 20156 Milan, Italy