New guidelines on attention deficit hyperactivity disorder fall short.
Sami Timimi
guardian.co Thursday 25 September 2008
Nice has announced new guidelines on the treatment of attention deficit hyperactivity disorder, or ADHD, in children.
In my view, though the new advice has taken some steps in the right direction, it suffers from a failure of nerve. Perhaps the guideline development group was unable to accept the challenge the evidence poses to currently accepted practice.
For example, Nice correctly concludes that the evidence does not support using medication (such as Ritalin) as a first-line treatment for mild or moderate ADHD, as medication has not been demonstrated to produce a better outcome than psychological approaches, but has been found to carry extra risks (such as interference with growth). Yet Nice concludes that medication should be used as a first-line treatment in "severe" ADHD, citing only one reference in support of this.
Even this reference is fundamentally flawed, as it refers to data from a large trial comparing medication and behavioural treatments, which concluded that the more severe subgroup showed a larger decrease in symptoms with medication than with therapy after 14 months in treatment.
However, after 36 months, this research project found no superiority in outcome for medication over behaviour therapy, even in those with more severe symptoms. At the same time, it found that children exposed to medication for the longest periods were now significantly lighter and shorter than their peers.
Recommending medication as a first-line treatment for "severe" ADHD is, therefore, not evidence-based, but provides an escape route for practitioners to continue misapplying medication to patients (by simply re-categorising them as severe cases).
The new guideline is also full of inconsistencies. For example, although Nice recognises that there is little robust evidence supporting the idea that ADHD is the result of a dysfunction in the brain and thus concludes "the diagnosis of ADHD does not imply a medical or neurological cause", they refer to ADHD as a "neurodevelopmental disorder" (ie, a disorder of the development of the nervous system). This is important, as it is paediatricians who deal with "neurodevelopmental disorders" and paediatricians have less exposure in their training to psychosocial approaches to assessment and treatment. The recommendations should have reflected the evidence, and so concluded that ADHD should not be classified as a "neurodevelopmental disorder", but a behavioural one that should be the remit of child and adolescent mental health services, rather than paediatrics.
The guidelines also widen the concept of ADHD by extending the diagnosis into adulthood. But this is based on a lack of evidence (that ADHD has different features in adulthood compared to childhood), rather than the presence of any (that, for example, ADHD can be reliably differentiated from similar presentations such as a mood or personality disorders).
Finally, the guidelines avoid some key issues – such as why this is a diagnosis given mainly to boys, and how to understand ADHD behaviours cross-culturally. Different cultures have different beliefs about what should be considered normal or deviant behaviour among children and what are appropriate child-rearing techniques. This, together with parenting classes featuring strongly as a recommended intervention, renders the guideline institutionally racist in my opinion, as it effectively imposes views of childhood and child-rearing on communities who have differing and perfectly functional alternative views. (Indeed, it is modern western culture where childhood behaviour problems have become most problematic).
The guidelines thus fall a long way short of the standards children and families deserve. The recommendations do not accurately reflect the evidence they used and are unlikely to challenge current practice – which is at best misguided, at worst positively harmful.
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