Anand Viswanathan
Distracting children is usually not difficult. It is easier to console a crying child than a sobbing adult, because children have a lower attention span. Also, growing children are naturally inquisitive, impulses drive their exploring tendencies, and thus, they tend to be more active than adults are.
Such virtues of childhood were generally considered normal, until the last century. Until when we started making a ‘disease’ out of the ‘symptoms’ of inattention, impulsivity and hyperactivity, naming it, unsurprisingly, ‘Attention Deficit Hyperactivity Disorder‘ (ADHD). As with other “diseases” that have been invented from just the variations in normal human body functions (think obesity and pre-diabetes) (1) , the criteria to diagnose ADHD are heavily subjective.(2) Contrast this from real disease conditions that mostly have more robust methods for diagnosis.
What is the general belief?
Doubts about diagnosis is just the beginning of the issue with ADHD. Methylphenidate, a brain-stimulant drug that is widely used as the first choice to “treat” children with ADHD, is believed to be useful in reducing the symptoms ascribed to ADHD.
What is the issue?
Like any other drug, Methylphenidate is not without its side-effects. Despite isolated studies supporting its use, until recently we did not know what the overall scientific evidence says about Methylphenidate use. We need to know whether this drug would definitely afford more benefits than harms, when used in children diagnosed to have Attention Deficit Hyperactivity Disorder
What is the scientific evidence about this?
A Cochrane systematic review published on 25 November 2015, that has systematically evaluated all available research evidence related to use of Methylphenidate in ADHD.(3)
Why was this Cochrane systematic review done?
To assess the beneficial and harmful effects of Methylphenidate for children and adolescents diagnosed with ADHD.
What were the findings in this review?
- Small improvements in children’s teacher-rated symptoms & general behaviour, and parent-reported quality of life were found with Methylphenidate use. The average difference in scores between Methylphenidate and ‘no treatment‘ groups was less than 10% of the respective total scores in all these outcomes.
- A definite increase in adverse effects: 29% more adverse effects among children treated with Methylphenidate compared to children that did not receive this treatment. The adverse effects could be as high as 51% more, or at best just 10% more than in the untreated children (RR 1.29, 95% CI 1.10 to 1.51; 21 trials, 3132 participants). Sleep disturbances and reduced appetite were the commonest adverse events.
- All the above inferences were supported by very low quality scientific evidence (on a 4-level quality scale of high, moderate, low, very-low).
What does this mean?*
- “At the moment…we cannot say for sure whether taking methylphenidate will improve the lives of children and adolescents with ADHD.
- Methylphenidiate is associated with … problems with sleeping and decreased appetite”.
My take: Diagnosing more children as inattentive and hyperactive, when in fact they may just be the natural themselves; and then treating them with brain stimulant drugs whose benefits are yet to be proven beyond reasonable doubt, while risking a higher chance of side effects- all this seems too gray to me. By lowering the bar for such branding, we probably are not only exposing more children to unnecessary drug treatments, but also doing a disservice to those children with severe symptoms of ADHD, who may actually benefit from such treatments. The ball lies in the courts of parents and physicians to act judiciously. When in doubt, let children be children.
*These blog posts are personal opinions of the author, and do not necessarily reflect the official views of the organization he represents. These are not intended to be directly used as healthcare guidelines. Reader discretion, as always, is recommended.
References:
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Yudkin JS, Montori VM. The epidemic of pre-diabetes: the medicine and the politics. The BMJ. 2014 Jul 15;349:g4485.2. Thomas R, Mitchell GK, Batstra L. Attention-deficit/hyperactivity disorder: are we helping or harming? The BMJ. 2013 Nov 5;347:f6172.3. Storebø OJ, Krogh HB, Ramstad E, Moreira-Maia CR, Holmskov M, Skoog M, et al. Methylphenidate for attention-deficit/hyperactivity disorder in children and adolescents: Cochrane systematic review with meta-analyses and trial sequential analyses of randomised clinical trials. BMJ. 2015 Nov 25;351:h5203.
Competing interests: Anand Viswanathan, a rehabilitation physician, currently works full time in a research position at Cochrane South Asia, Christian Medical College, Vellore- India. He could be reached at @anandtmc . Richard Kirubakaran, one of the co-authors of the Cochrane review on Methylphenidate, is also currently employed at Cochrane South Asia.
Evidence Nutshell 