Correspondence
Attention-Deficit–Hyperactivity Disorder
N Engl J Med 1999; 340:1766-1767June 3, 1999
- Article
To the Editor:
In their review of attention-deficit–hyperactivity disorder (ADHD), Zametkin and Ernst (Jan. 7 issue)1 acknowledged the eightfold rise in the use of stimulants in the United States over the past decade. They did not mention that the use of methylphenidate (Ritalin) in the United States accounts for 90 percent of the use worldwide.2 In the United States, per capita use of methylphenidate varies sixfold among states.3 Within individual states, analyses based on ZIP Codes show 20-fold variations from one community to the next.3 Such large variations in the use of stimulants point to factors other than neurologic ones in the diagnosis of ADHD and treatment with stimulants. The wide variation may be accounted for by social, cultural, and economic influences, which include the readiness to accept a biologic explanation and medical intervention for behavioral problems, fears of educational failure, access to medical systems, and parenting styles.4 Cultural factors specific to the United States should be explored further to help in determining whether the unique approach to children's performance and behavioral problems in the United States represents progress or is a sign that we are either expecting too much or not meeting the needs of our children, their families, and schools.
4 ReferencesLawrence H. Diller, M.D.
2099 Mount Diablo Blvd., Walnut Creek, CA 945961
Zametkin AJ ,Ernst M . Problems in the management of attention-deficit-hyperactivity disorder. N Engl J Med 1999;340:40-46
Full Text | Web of Science | Medline2
UN International Narcotics Control Board. Report of the UN International Narcotics Control Board, 1994. New York: UN Publications, 1995.
3
Spanos B. Quotas, ARCOS, UN Report and Statistics. Conference report: stimulant use in the treatment of ADHD. Washington, D.C.: Drug Enforcement Administration, December 1996.
4
Diller LH. Running on Ritalin: a physician reflects on children, society, and performance in a pill. New York: Bantam Books, 1998.
To the Editor:
In their discussion of the clinical evaluation for ADHD, Zametkin and Ernst emphasized the need to consider possible underlying or alternative medical diagnoses, including some as rare as generalized resistance to thyroid hormone and others as common as depression, because the identification and treatment of such conditions might also improve symptoms of ADHD. The differential diagnosis also could have included primary sleep disorders. Children with obstructive sleep apnea are often thought to have ADHD and receive treatment with stimulants for years before diagnosis of their sleep disorder. In such cases, treatment by tonsillectomy or nasal continuous positive airway pressure can lead to the resolution of inattention and hyperactivity and to the discontinuation of medication.1
Although sleep disorders have not yet been proved to cause ADHD, initial data suggest that experimental sleep deprivation produces symptoms similar to those seen in ADHD.2 Some sleep disorders are so common — obstructive sleep apnea alone is estimated to affect between 0.7 and 3 percent of children3 — that if these disorders do cause inattention and hyperactivity, a substantial number of children who carry the diagnosis of ADHD might benefit from thorough sleep evaluations. Survey data from my institution on the excess frequency of snoring among hyperactive children have suggested that as many as 25 percent of children who have received a diagnosis of ADHD might not have this disorder if snoring and any associated sleep-disordered breathing were diagnosed and treated.4
4 ReferencesRonald D. Chervin, M.D.
University of Michigan Health System, Ann Arbor, MI 481091
Ali NJ ,Pitson D ,Stradling JR . Sleep disordered breathing: effects of adenotonsillectomy on behaviour and psychological functioning. Eur J Pediatr 1996;155:56-62
Web of Science | Medline2
Sadeh A. Sleep and neurobehavioral functioning in Israeli school-age children: implications for ADHD. Presented at the 10th International Annual Conference of CHADD (Children and Adults with Attention-Deficit/Hyperactivity Disorder), New York, September 1998.
3
Gislason T ,Benediktsdottir B . Snoring, apneic episodes, and nocturnal hypoxemia among children 6 months to 6 years old: an epidemiologic study of lower limit of prevalence. Chest 1995;107:963-966
CrossRef | Web of Science | Medline4
Chervin RD ,Dillon JE ,Bassetti C ,Ganoczy DA ,Pituch KJ . Symptoms of sleep disorders, inattention, and hyperactivity in children. Sleep 1997;20:1185-1192
Web of Science | Medline
To the Editor:
In their review, Zametkin and Ernst state that ADHD persists into adulthood, with 8 to 66 percent of children still meeting criteria for the full disorder in late adolescence and young adulthood. There is little information about ADHD in adults, but it has been suggested that ADHD is being diagnosed in an increasing number of adults.1 Using data from the National Ambulatory Medical Care Survey for the period from 1990 through 1995, we discerned a 2.5-fold increase in the number of office-based physician–patient encounters in which a diagnosis of ADHD in a school-age child was documented.2
We examined data from the National Ambulatory Medical Care Survey for 1995 and 19963,4 for office-based physician–patient encounters in which a diagnosis of ADHD in an adult was documented (Table 1Table 1
Data from Visits to Physicians' Offices in Which a Diagnosis of ADHD Was Recorded for Patients 20 to 70 Years of Age, 1995 and 1996.). The majority of patients had been prescribed stimulant pharmacotherapy, usually methylphenidate. Men accounted for 43.4 percent of the patients in 1995 and 64 percent in 1996. Nearly all patients were non-Hispanic whites. A diagnosis of a concomitant mental disorder was recorded for 80.2 percent of the adult patients with ADHD in 1995 and 63.2 percent in 1996; depression was the dominant coexisting disorder. The majority of the visits were reported by psychiatric specialists.In 1996, 18.4 percent of all patients with a recorded diagnosis of ADHD were 20 years of age or older. A greater emphasis is needed on initial childhood screening and continuity of care throughout life.
4 ReferencesLinda M. Robison, M.S.P.H.
David A. Sclar, B.Pharm., Ph.D.
Tracy L. Skaer, Pharm.D.
Washington State University, Pullman, WA 99164-65101
Murphy K . Adults with attention deficit hyperactivity disorder: assessment and treatment considerations. Semin Speech Lang 1996;17:245-253
CrossRef | Medline2
Robison LM, Sclar DA, Skaer TL, Galin RS. National trends in the prevalence of attention-deficit/hyperactivity disorder and the prescribing of methylphenidate among school-age children: 1990-1995. Clin Pediatr (in press).
3
Woodwell DA. National Ambulatory Medical Care Survey: 1995 summary. Advance data from vital and health statistics. No. 286. Hyattsville, Md.: National Center for Health Statistics, 1997. (DHHS publication no. (PHS) 97-1250.)
4
Woodwell DA. National Ambulatory Medical Care Survey: 1996 summary. Advance data from vital and health statistics. No. 295. Hyattsville, Md.: National Center for Health Statistics, 1997. (DHHS publication no. (PHS) 98-1250.)
Author/Editor Response
The authors reply:
To the Editor: We agree with Dr. Diller that the use of methylphenidate in this country represents 90 percent of the use worldwide and that there are large variations in use among ZIP Codes. However, we take exception to his interpretation of the data. First, the data that he cites were not corrected for census or population. ZIP Codes in densely populated areas will have greater total use than those in sparsely populated areas. ZIP Code data can be highly misleading. Second, use will be highly correlated with the number of physicians practicing in an area. Certainly there are real differences in prescribing practices in different areas. But does variability in identification and treatment of a problem necessarily reflect the validity of the disorder as biologically mediated or neurologically based?
Even if the data were valid, the logic Diller uses to make his point is not valid. He implies that parenting style and fears of lack of achievement by children motivate parents to medicate a social and cultural problem. The immense literature on the genetics of the disorder, the sequelae, and 50 years of biologically based research argue against Dr. Diller's interpretation.
Dr. Chervin gives a reminder that sleep disorders should be considered in inattentive children, and we agree that this possibility should not be forgotten. Obviously, formal sleep studies are not part of the evaluation of children in whom ADHD is suspected. As part of the evaluation, several questions in this area might very well be productive. Data from careful investigation of this phenomenon would be welcome.
Alan J. Zametkin, M.D.
National Institute of Mental Health, Bethesda, MD 20892Monique Ernst, M.D., Ph.D.
National Institute on Drug Abuse, Baltimore, MD 21334- Citing Articles (3)
Citing Articles
1
Shlomo Vinker, Rina Vinker, Asher Elhayany. (2006) Prevalence of Methylphenidate Use among Israeli Children. Clinical Drug Investigation 26:3, 161-167
CrossRef2
Stephen V. Faraone. (2005) The scientific foundation for understanding attention-deficit/hyperactivity disorder as a valid psychiatric disorder. European Child & Adolescent Psychiatry 14:1, 1-10
CrossRef3
Jane F. Gaultney, Debra F. Terrell, Jeannine L. Gingras. (2005) Parent-Reported Periodic Limb Movement, Sleep Disordered Breathing, Bedtime Resistance Behaviors, and ADHD. Behavioral Sleep Medicine 3:1, 32-43
CrossRef
