This annual report - Taranaki District Health Board

EpidemiologyThe 2009 review by Merikangas et al. reported on the prevalence rates of ADHD(according to DSM-IV criteria) in recent community surveys in the U.K. and the U.S. [315].More recent studies have found that the point prevalence if ADHD in 5–15 year olds was2.23% [404] and that 12-month prevalence for 4–17 year olds ranged from 2% to 8.7%[405,406,407]. Population surveys have consistently found a higher prevalence of ADHD inboys than girls as follows: 11.8% in boys and 5.4% in girls [406], 3.62% in boys and 0.85%in girls [404], 2.0% for boys and 0.5% for girls [407], and 1.5% for boys and 0.3% for girls[408]. There is conflicting evidence on whether or not ADHD is linked with socio-economicstatus [404,405,406,407].ComorbidityComorbidity (having more than one disorder) is common in children with ADHD. Between25% and 50% of children diagnosed with ADHD also meet the criteria for OppositionalDefiant Disorder or Conduct Disorder, 25% have an anxiety disorder, 20% a mooddisorder, and 20% a specific developmental disorder (such as a specific learning disorder,language-based difficulties or motor coordination problems). Academic and school failureis common. Many children with Tourette’s syndrome also meet the criteria for ADHD [409].TreatmentThere is a vast literature on the treatment of ADHD and numerous published guidelines,including a New Zealand one published in 2001 [410]. The National GuidelineClearinghouse in the U.S. offers a brief synthesis [411] of the recent guidelines from theAmerican Academy of Child and Adolescent Psychiatry (AACAP) [412], and the ScottishIntercollegiate Guidelines Network (SIGN) [409].Pharmacological TreatmentThe primary treatment for the core symptoms of ADHD is medication and most childrenwith ADHD respond positively to one or more drugs. SIGN, and, according to the AACAP,the American Academy of Pediatrics, an international consensus statement and the TexasChildren's Medication Project, all recommend psychostimulants as the first line treatmentfor ADHD. These agents include methylphenidate (Rubifen TM and Ritalin TM ) anddexamphetamine (Dexedrine TM ). These agents have been the subjects of numerous RCTsand their efficacy and safety is well established [413].SIGN does not recommend medication for pre-schoolers but the AACAP states thatstimulants are widely prescribed in this age group despite the limited number of publishedcontrolled trials and it cites research suggesting that dosages should be more conservativein pre-schoolers than school age children. Both SIGN and AACAP agree that amoxetine (anoradrenergic reuptake inhibitor) is superior to placebo, but inferior to psychostimulants,for the treatment of core symptoms of ADHD. SIGN suggests amoxetine for children inwhom psychostimulants are not tolerated, ineffective or inappropriate, and AACAPsuggests that amoxetine may be considered as a primary medication in individuals withsubstance abuse problems, comorbid anxiety or who experience severe side effects frompsychostimulants (such as mood lability or tics). Both guidelines agree that patients takingamoxetine should be monitored for suicidal ideation, worsening mood or unusualbehaviour changes.Both guidelines cover the use of unlicensed medications for ADHD, including clonidine andguanfacine (alpha agonists) and tricyclic antidepressants, all of which may be appropriatein certain circumstances, and bupropion (for which there is little evidence of effectiveness).SIGN found insufficient evidence on which to base a recommendation for either reboxetineor selegiline.Behavioural InterventionsWhile medication is generally more effective than psychological treatments for ADHD, bothSIGN and AACAP agree that behaviour therapy alone is appropriate in somecircumstances, including mild ADHD, diagnostic uncertainty and parental rejection ofmedication. SIGN recommends behavioural parent training alone for parents of preschoolers.In-Depth Topic: Mental Health Issues in Children - 378