Childhood attention-deficit/hyperactivity disorderBMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h2168 (Published 20 May 2015) Cite this as: BMJ 2015;350:h2168
All rapid responses
We highly appreciate Dr Verkuijl’s response to our comments (1). Nonetheless, we still disagree with some aspects and think useful to stress several remarks:
1. In our view, even considering the evidence from MTA study, there is no room to state firmly that ‘drugs can improve core symptoms, school performance and peer relationships’. This trial suffered from important limitations (2), especially the absence of a necessary placebo group. Regarding the ‘community care’ arm, it can’t be viewed as a reliable reference because, among other aspects, some 67% participants in this group already received drugs. In any case, all the differences pointed out in favour of the ‘combination group’ and ‘medication group’ are related to core ADHD symptoms, which seem to disappear at the long run (3). Moreover, the reply doesn’t add a word on what would support a better school performance with drugs or a proper way to identify ADHD ‘severe cases’ (1).
2. Children participating in the ADHD Voices project show some acceptance of medication but, at the same time, they clearly demand for other therapeutic alternatives (4). On the other hand, as we stated previously, other publications have outlined their rejection of medication (5), indirectly manifested by a high rate of non-compliance with treatment (6). So in our view, this topic should not be considered as a closed issue.
The question of heredability
3. Unfortunately, studies involving MZ twins reared apart (TRA) are very rare and contain important problems, which include the questionable separation of twins, similarity bias of the samples, failure to publish or share raw data and life history information for the twins under study, researchers’ bias in favour of genetic explanations and scant attention paid to important shared environmental influences (7). In fact, the more and more heterogeneity of the individuals diagnosed makes the problem of heredity even harder and continues to be a relevant problem before any definitive conclusion can be made in this direction (8).
ADHD advocacy groups
4. Finally, ADHD advocacy groups sponsored by the pharmaceutical industry, among them many national parent groups, are often unaware of the huge collateral consequences that this relationship causes, turning a blind eye to what research has repeatedly shown (9). Moreover, there is a substantial lack of transparency. In Spain, for example, the Spanish Federation of Associations to Aid in ADHD (FEAADAH) has not been able to facilitate the information we asked for on their activities, budget and sources of funding.
5. That said, we agree that behavioral problems must be managed in order to prevent dysfunctional interactions with peers, family or school. However, it needs to be considered that stigma can also come from the own drug support. The pill arrives to reinforce (and sometimes reformulate) the identity of the young child, leading to a drug-conditioned autonomy that can undervalue their own abilities. Putting children first can't be achieved mainly through drugs (Figure 1). All for the children 'Yes', but also ‘with’ the children (8).
(1) Rebuttal to Dr Luis Carlos Saiz and colleagues’ rapid response. http://www.bmj.com/content/350/bmj.h2168/rr-1
(2) The MTA Cooperative Group. A 14-month randomized clinical trial of treatment strategies for Attention-Deficit/Hyperactivity Disorder. Arch Gen Psychiatry 1999;56:1073-86.
(3) Molina BSG, Hinshaw SP, Swanson JM, Arnold LE, Vitiello B, Jensen PS, et al. The MTA at 8 years: Prospective follow-up of children treated for combined type ADHD in a multisite study. J Am Acad Child Adolesc Psychiatry 2009;48(5):484-500.
(4) Singh I. A disorder of anger and aggression: Children’s perspectives on attention deficit/hyperactivity disorder in the UK. Soc Sci Med 2011;73(6):889-96.
(5) Sleator EK, Ullmann RK, von Neumann A. How do hyperactive children feel about taking stimulants and will they tell the doctor? Clin Pediatr 1982;21(8):474-9.
(6) Pappadopulos E, Jensen PS, Chait AR, Arnold LE, Swanson JM, Greenhill LL, et al. Medication adherence in the MTA: saliva methylphenidate samples versus parent report and mediating effect of concomitant behavioural treatment. J Am Acad Child Adolesc Psychiatry 2009;48(5):501-10.
(7) Joseph J. Genetic research in psychiatry and psychology: a critical overview. In K. Hood, C. Tucker Halpern, G. Greenberg, & R. Lerner (Eds.), Handbook of Developmental Science, Behaviour and Genetics (pp. 557-625). Malden, MA: Wiley-Blackwell.
(8) Saiz LC. Pay attention to the Attention Deficit Hyperactive Disorder (ADHD): between an uncertain nature and a hyperactive prescription. DTB Navarre 2013;21(5):1-19.
Competing interests: No competing interests
We would like to thank Dr Luis Carlos Saiz and colleagues for their rapid response to our Clinical Review: Childhood attention-deficit/ hyperactivity disorder (ADHD). (1) There are a number of points they make that might benefit from further clarification. These will be addressed in turn:
1. That we have placed ‘too positive a view of medication’, in the Bottom line statement by stating that ‘drugs can improve core symptoms, school performance and peer relationships’
We feel this is a valid point, and it would probably have helped to have included an additional point to ’The Bottom line’ stating that: ‘More research is needed to ascertain the long term efficacy and adverse effects of both drug and psychosocial interventions.’
This would highlight early in the Review the uncertainties and limitations of the current evidence-base for the longer-term use of drugs, which we do address later in the review, where we describe how studies lack long term follow up data to support the use of drugs for ADHD. (2) (3)
We do, however, still feel able to say that: ‘Drugs can improve core symptoms, school performance and peer relationships’ as found also in the MTA study, where after 14 months of treatment both the ‘combined medication and behaviour treatment’ and ‘medication management’ were generally superior to community care for parent- and teacher-reported child ADHD symptoms, whereas just behavioural treatment was not. (4)
They also mention the impressive ADHD Voices project (www.adhdvoices.com), which interviewed a large cohort of children with ADHD. The sample was not set up to be representative, but it did ask children about their experience of medication. Interestingly, the majority had a positive experience of medication, they found it a useful adjunct to the other strategies they used to manage their ADHD. They described it as ‘helping them be the person they wanted to be’ by allowing them, for example, to be less impulsive. A minority of children (8%), reported not feeling like themselves due to the side effects of the medication. (5)
2. Overstating genetic causes of ADHD
Differences in ADHD concordance between monozygotic (MZ) and dizygotic (DZ) twins indicate that ADHD has a heritability of 70-80%. However, MZ twins experience more similar environments than DZ twins, and you point out that that this could explain their excess similarity. A number of studies have addressed this possibility, and across a large number of traits, have concluded that estimates from more powerful designs, involving for example, MZ twins reared apart or large family trees, give similar estimates to twin studies. (6)
3. Lastly, the label ADHD is an unhelpful one
Some researchers (7), parents and teachers have voiced similar opinions to yours. However, national parent groups for ADHD, as well as a range of other professionals have disagreed with this stance, for example, the parents have been concerned that without the diagnosis, their child would go back to receiving the: ‘naughtiest child of the class’ or ‘worst behaved’ label which they felt gave less room for reducing stigma and increasing the understanding of their child’s difficulties. (8)(9)
1. Rapid Response: ADHD drug treatment should be deemed according to its weak evidence. http://www.bmj.com/content/350/bmj.h2168/rr-0
2. Molina BS, Hinshaw SP, Swanson JM et al. MTA Cooperative Group. The MTA at 8 years: prospective follow-up of children treated for combined-type ADHD in a multisite study. J Am Acad Child Adolesc Psychiatry 2009 May; 48(5): 484-500. doi:10.1097/CHI.0b013e31819c23d0.
3. Riddle MA, Yershova K, Lazzaretto D, et al. The Preschool Attention-Deficit/Hyperactivity Disorder Treatment Study (PATS) 6-year follow-up. J Am Acad Child Adolesc Psychiatry 2013 Mar; 52(3): 264-278.e2. doi:10.1016/j.jaac.2012.12.007
4. The MTA Cooperative Group. A 14-Month randomized clinical trial of treatment strategies for Attention-Deficit/Hyperactivity Disorder. Arch Gen Psychiatry 1999; 56: 1073-86.
5. Singh I. Not robots: children's perspectives on authenticity, moral agency and stimulant drug treatments. J Med Ethics 2013 Jun; 39(6): 359-66. doi: 10.1136/medethics-2011-100224.
6. Martin N, Boomsma D, Machin G. A twin-pronged attack on complex traits. Nat Genet 1997 Dec; 17(4): 387-92.
7. Batstra L, Nieweg EH, Hadders-Algra M. Exploring five common assumptions on Attention Deficit Hyperactivity Disorder. Acta Paediatr 2014 Jul; 103(7): 696-700.
9. Timimi S, Taylor E. ADHD is best understood as a cultural construct. Br J Psychiatry 2004 Jan;184:8-9.
Competing interests: No competing interests
We agree with Dr Verkuijl and colleagues (1) when they warn us about the huge influence of industry, admit the scarcity “of good quality experimental data” and recognize numerous unanswered questions on ADHD drug treatment, including “long term effects” and ”limitations of the studies for methylphenidate”. That said, it is not clear that they finally draw the right conclusions from these premises. The authors show a very optimistic view when they state in the ‘Bottom line’ of their article that “drugs can improve core symptoms, school performance and peer relationships”. Even if a short-term efficacy on some symptoms is taken for granted, the whole sentence seems to be too hard to be proved according to sound evidence.
First, after 14 months of treatment not all core ADHD symptoms were better in the drug arm of the prominent MTA trial, because conflicting results were found between parents and teachers in the hyperactivity outcome (2). Secondly, nothing specific supporting a better school performance with drugs can be read in the text (1). And finally, the only mention to improved relationships caused by drugs comes from such a tiny study (N=16) that little can be concluded. Regarding this, other experiences with larger sizes have been published (VOICES, N=151; Sleator et al, N=52), showing plural opinions among children treated by stimulants (3,4). Hence, while lacking evidence in long relevant outcomes seems to be admitted, this is surprisingly no obstacle to recommend drug treatment for “severe cases where impairment is demonstrable”. What does ‘severe cases’ really mean? And why should we put our trust in drugs with insufficient background?
On the other hand, “high heritability” is claimed as a major cause of ADHD, mainly supported by twins studies, obviating that the assumption of an equivalent environment among twins and non identical siblings is in fact highly problematic (5). Of course, the hereditary factor is used to support the thesis of ADHD as a chronic disorder. Unfortunately, despite the enormous research effort dedicated to this task, so far no consistent marker has been identified for ADHD and all we have are eternally candidate genes (5).
Looking at young people's and parents' stories, normal life problems seem to be present. There is no need for diagnostic labels to understand and face them. Academic performance lower than expected can be a real source of stress but it is far from being a disease. In these cases, medication can just be considered a way for cognitive enhancement, not a treatment.
In short, we find this review an attempt to reach a balanced assessment of ADHD management, but it is perhaps still too indulgent of the ‘official’ paradigm weaknesses, in which biased bibliographical support is probably over-represented. We see that Green and Chee's book ‘Understanding ADHD’ has been recommended as a useful resource. Now, we are wondering if anyone has paid the same attention to ‘Misunderstanding ADHD’, Timimi’s answer (6). After reading carefully the article, we honestly don’t think so.
(1) Verkuijl N, Perkins M, Fazel M. Childhood attention-deficit/hyperactivity disorder. BMJ 2015;350:h2168. DOI:10.1136/bmj.h2168.
(2) The MTA Cooperative Group. A 14-Month randomized clinical trial of treatment strategies for Attention-Deficit/Hyperactivity Disorder. Arch Gen Psychiatry 1999;56:1073-86.
(3) Sing I. A disorder of anger and aggression: Children’s perspectives on attention deficit/hyperactivity disorder in the UK. Soc Sci Med 2011;73(6)889-96.
(4) Sleator EK, Ullmann RK, von Neumann A. How do hyperactive children feel about taking stimulants and will they tell the doctor? Clin Pediatr 1982;21(8):474-9.
(5) Joseph J, Ratner C. The fruitless search for genes in psychiatry and psychology: time to re-examine a paradigm. In S. Krimsky & Gruber (Eds.), Genetic Explanations: sense and nonsense (pp. 94-106). Cambridge, MA: Harvard Univesity Press. 2013.
(6) Timimi S. Mis-understanding ADHD. The complete guide for parents to alternatives to drugs. Authorhouse (Eds.). 2007.
Competing interests: No competing interests
Hyperactive syndrome and attention-deficit hyperactivity disorder (ADHD) treatment, from the perspective of the holistic method of Maria Summer, Rankweil/Austria.
Applied Speech therapy (Angewandte Logopaedie)
This method, developed and perfected by Maria Summer in Rankweil Austria, is for quick and effective treatment of disorders of speech, voice, breathing and learning, in approximately 60 sessions, without medication.
Breathing, posture, myokinetic exercises, are alternated in order to educate and cure the child.
Competing interests: No competing interests