BS Molina

E Ban van den

JG Hugtenburg

LM Pelsser

Pieter J. Hoekstra

S Tremmery

English

PubMed

Hoekstra, Pieter J.

University of Groningen

Is there potential for the treatment of children with ADHD beyond psychostimulants?

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EDITORIAL
Is there potential for the treatment of children
with ADHD beyond psychostimulants?
Pieter J. Hoekstra
Published online: 12 August 2011
 The Author(s) 2011. This article is published with open access at Springerlink.com
The past decades have seen a tremendous rise in the use of
methylphenidate in children and adolescents. While the
overall prevalence of psychotropic drug use in children and
adolescents in the Netherlands doubled between 1995 and
2001, that of methylphenidate alone almost rose sixfold in
those years [1]. Between 2001 and 2006, a further large
increase was observed in the prescription rates of methyl-
phenidate, not only in children and adolescents but also in
adults [2]. While rates of methylphenidate use are still
clearly highest amongst boys aged 6–11 years, the most
rapid increase in prevalence rate of methylphenidate use
has actually been seen in girls. Between 1996 and 2006 this
has risen more than 11.5-fold in girls, according to a
pharmacoepidemiological study conducted in the North of
the Netherlands [3]. To put this into perspective: the latter
study pointed out that the use of methylphenidate in girls in
2006 was almost double that of boys back in 1996.
The increased use of methylphenidate contrasts with the
lack of long term data on safety and effectiveness. Much of
our knowledge about treatment periods of longer than a
year comes from following up one study, the Multimodal
Treatment of attention deficit/hyperactivity (ADHD) study
(MTA) study. Although it should not be forgotten that all
MTA data beyond the initial controlled period of
14 months has been strictly observational, so far long term
benefits of optimized and well controlled methylphenidate
treatment during a limited period of time of 14 months
have been hard to demonstrate [4]. Thus, while on one
hand, there are clear short-term benefits of methylphenidate
for the treatment of ADHD, the uncertainty of long term
benefits and risks remains an urgent challenge for the sci-
entific and clinical community.
What promise may alternative treatments offer for
children with ADHD? Food-based interventions may be
one option. In 2009, this Journal had published promising
effects of a restricted elimination diet in reducing symp-
toms of ADHD versus a waiting list control group [5].
Results were recently confirmed in a larger scale Lancet
study by the same group of investigators, in which there
was a control group that received instructions for a healthy
diet [6]. However, the difficulty of establishing a truly
blinded control intervention constitutes perhaps the biggest
design challenge in trying to more firmly demonstrate the
efficacy of food-based treatments for ADHD. Ideally, well-
designed and controlled replication studies should be
conducted by independent groups who did not develop the
intervention themselves.
Another alternative treatment option that has now seen a
number of randomized controlled trials is electroencepha-
logram (EEG)-based neurofeedback. This issue (Bakhsha-
yesh et al.) contains a small-scale, but elegantly designed
randomized controlled trial of EEG neurofeedback versus a
sham condition (biofeedback aimed at forehead muscle
relaxation). Importantly, children and parents were not
explicitly informed about the two treatment conditions.
Results indicated both specific effects of EEG neurofeed-
back (reduction of inattention symptoms on parent rating
scales and reaction time in neuropsychological tests), as
well as non-specific factors (regarding hyperactivity and
impulsivity), which were similarly improved in the chil-
dren receiving the sham treatment.
Another study in this issue (Benjet et al.), using an
epidemiological approach (based on interview data of more
P. J. Hoekstra (&)
Department of Psychiatry, University Medical Center
Groningen, University of Groningen, Hanzeplein 1,
9713 GZ Groningen, The Netherlands
e-mail: p.hoekstra@accare.nl
123
Eur Child Adolesc Psychiatry (2011) 20:431–432
DOI 10.1007/s00787-011-0212-2
than 3,000 adolescents from the Mexican Adolescent
Mental Health Survey) once more reminded us that it is not
all genetics and neurobiology that determines mental dis-
orders. Rather, it pointed to the important role of family
dysfunctioning for the development of psychopathology.
As the authors conclude, their study findings at least indi-
rectly provide further evidence for the importance of
family focused intervention and prevention efforts.
With the ever rising prescription rates of methylpheni-
date, all too easily impressions of overtreatment rather than
undertreatment of ADHD in children may arise. However,
many children with impairing ADHD still receive no
proper treatment [7]. Thus, effective and easy-to-imple-
ment screening questionnaires that can identify those
children who are at risk of having ADHD or other
behavioral disorders are crucial. The Strengths and Diffi-
culties Questionnaire (SDQ) is one well-known example of
a brief screening instrument. Ullebø and colleagues [8] in
this issue describe that already the use of the 5-item-only
SDQ hyperactivity- inattention subscale has adequate
sensitivity for detecting ADHD combined subtype.
Are we overtreating children with methylphenidate?
There may be both over- and undertreatment. It remains an
enormous challenge for the scientific community to more
precisely establish the long-term risks and benefits of
methylphenidate treatment and also to determine in which
cases treatment with psychostimulants or alternative
treatments are warranted. Well-designed studies involving
alternative treatments remain urgently needed.
Open Access This article is distributed under the terms of the
Creative Commons Attribution Noncommercial License which per-
mits any noncommercial use, distribution, and reproduction in any
medium, provided the original author(s) and source are credited.
References
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123


A randomised controlled trial into the effects of food on ADHD.

Effects of a restricted elimination diet on the behaviour of children with attention-deﬁcit hyperactivity disorder (INCA study): a randomised controlled trial.

Increased psychotropic drug consumption by children in the Netherlands during 1995–2001 is caused by increased use of methylphenidate by boys.

Large increase of the use of psycho-stimulants among youth in the Netherlands between

Screening for the attention deﬁcit hyperactivity disorder phenotype using the strength and difﬁculties questionnaire. Eur Child Adolesc Psychiatry. doi:10.1007/s00787-011-0198-9 432 Eur Child Adolesc Psychiatry

The MTA at 8 years: prospective follow-up of children treated for combinedtype ADHD in a multisite study.

The use of health care services and psychotropic medication in a community sample of 9-year-old schoolchildren with ADHD. Eur Child Adolesc Psychiatry 16(5):327–336 Epub

Trends in incidence and characteristics of children, adolescents, and adults initiating immediate- or extended-release methylphenidate or atomoxetine in the Netherlands during 2001–2006.

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Is there potential for the treatment of children with ADHD beyond psychostimulants?

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Dissertations of the University of Groningen

Dissertations of the University of Groningen

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Proceedings - University of Groningen