Treatment of attention- deficit hyperactivity disorder
======================================================

* Laurence Jerome

Benedetto Vitiello's thoughtful commentary1 on 2 recent articles on the short-term effectiveness of methyl-phenidate corrects the omission of the very important MTA study2 from the meta-analysis by Howard Schachter and colleagues.3 Vitiello's question concerning the impact on long-term outcomes of reducing the symptoms of attention-deficit hyperactivity disorder cannot be considered in isolation from the multiple comorbidities that accompany attention-deficit hyperactivity disorder and that are not affected directly by medication. Behavioural, educational, substance use and family psychopathologic issues call for a comprehensive multimodal management approach.

One important message of the MTA study is that for the vast majority of children with attention-deficit hyperactivity disorder, effective treatment begins with a well-monitored medication trial that opens the door for other management approaches. The MTA study also demonstrated that routine community trials of stimulants are not as effective as carefully monitored trials that follow research protocols. For example, we do not have good data on how community physicians monitor trials of methylphenidate. Indirect information from teacher surveys4 suggests that physicians do not routinely enlist teachers' help in monitoring the effect of medications in the classroom. Teachers should fill out rating scales on an ongoing basis; this easy, if time-consuming, task is an essential component of any adequate trial of treatment with stimulants.

Vitiello's point concerning the lack of data on whether or not treatment with stimulants decreases the risk of accidental trauma is timely. The literature on attention-deficit hyperactivity disorder has demonstrated a significantly increased risk of driving problem behaviours in people with attention-deficit hyperactivity disorder. This issue is addressed in the latest edition of the CMA's recommendations to physicians concerning medical fitness to drive.5 Recent clinical reports have examined the subjective and objective benefits of stimulant medications for driving performance in adults diagnosed with adult attention-deficit hyperactivity disorder.6,7,8 

**Laurence Jerome** Consultant Psychiatrist Amethyst Program Provincial Demonstration School London, Ont.

## References

1.  1. Vitiello B. Methylphenidate in the treatment of children with attention-deficit hyperactivity disorder [editorial]. CMAJ 2001;165(11):1505-6.
    
    [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czoxMToiMTY1LzExLzE1MDUiO3M6NDoiYXRvbSI7czoyNDoiL2NtYWovMTY2LzEwLzEyNTEuMy5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

2.  2. The MTA Cooperative Group. A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder (ADHD). Arch Gen Psychiatry 1999;56:1073-86.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1001/archpsyc.56.12.1073&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=10591283&link_type=MED&atom=%2Fcmaj%2F166%2F10%2F1251.3.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=000084053100001&link_type=ISI) 

3.  3. Schacter HM, Pham B, King J, Langford S, Moher D. How efficacious and safe is short-acting methylphenidate for the treatment of attention-deficit disorder in children and adolescents? A meta-analysis. CMAJ 2001;165(11):1475-88.
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czoxMToiMTY1LzExLzE0NzUiO3M6NDoiYXRvbSI7czoyNDoiL2NtYWovMTY2LzEwLzEyNTEuMy5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

4.  4. Jerome L, Gordon M, Hustler P. A comparison of American and Canadian teachers' knowledge and attitudes towards attention deficit hyperactivity disorder (ADHD). Can J Psychiatry 1994;39: 563-7.
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=7874659&link_type=MED&atom=%2Fcmaj%2F166%2F10%2F1251.3.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=A1994QG20400009&link_type=ISI) 

5.  5. *Determining medical fitness to drive: a guide for physicians*. 6th ed. Ottawa: Canadian Medical Association; 2000.
    
    

6.  6. Cox DJ, Merkel RL, Kovatchev B, Seward R. Effect of stimulant medication on driving performance of young adults with attention-deficit hyperactivity disorder.J Nerv Ment Dis 2000;188 (4):230-4.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1097/00005053-200004000-00006&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=10790000&link_type=MED&atom=%2Fcmaj%2F166%2F10%2F1251.3.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=000086467900006&link_type=ISI) 

7.  7. Jerome L, Segal A. ADHD, executive function, and problem driving. *ADHD* Rep 2000;8(2):7-11.
    
    

8.  8. Jerome L. Benefit of long term stimulants on driving in adults with ADHD.J Nerv Ment Dis 2001; 189(1):36-64.