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Home > Comment > BMJ
2008;337:a2284, doi: 10.1136/bmj.a2284 (Published 28 October 2008)

Published 28 October 2008, doi:10.1136/bmj.a2284
Cite
this as: BMJ 2008;337:a2284

Letters

NICE guidance on ADHD

NICE recommendations are not evidence based and could expose many to
unnecessary harm

The National Institute for Health and Clinical Excellence’s
(NICE’s) single most important recommendation is for medication
to be used as a first line treatment in "severe"
attention-deficit/hyperactivity disorder (ADHD).1
Like other systematic reviews of ADHD medication treatment, NICE
notes the inadequate reporting of study methodology, possible bias,
limited reliability of results, and inadequate data regarding adverse
events, correctly concluding that the evidence does not support using
medication as a first line treatment for mild or moderate ADHD. Yet
NICE concludes that medication should be used as a first line
treatment in "severe" ADHD, with only one reference cited in support
of this2
(which is a reanalysis of the data from the largest trial comparing
medication and behavioural treatments), which concludes that the more
severe subgroup showed a larger decrease in symptoms with
medication than with behaviour therapy. However, these data were
gathered 14 months after the beginning of the study. Swanson et al,
analysing the same group of patients after 36 months, could not find
support for long term benefits of medication over behaviour
therapy, even in those with more severe symptoms.3

These guidelines are likely to expose many children and adults to
unnecessary harm. The recommendations are not supported by the
evidence analysed by NICE. The evidence should lead to the
conclusions that ADHD is a disorder of questionable validity,
particularly as a diagnosis for adults, and use of medication
should be a "research only" recommendation.

Cite this as: BMJ 2008;337:a2284

Sami Timimi, consultant child and adolescent
psychiatrist1, Jon Jureidini,
consultant child and adolescent psychiatrist2,
Jonathan Leo, associate professor of
neuroanatomy3

1 Lincolnshire Partnership Foundation NHS Trust, Lincoln LN4 2HN,
2 Women’s and Children’s Hospital, Adelaide, Australia, 3
Lincoln Memorial University, Harrogate, USA

stimimi{at}talk21.com

Competing interests: Sami Timimi was invited to give
evidence to a one day conference organised by NICE ADHD Guidelines
development group, and has commented on earlier drafts of the
guideline. Jonathan Leo was a peer reviewer for the first draft of
the NICE ADHD guidelines, examining the "validity" of ADHD.

References

Kendall T, Taylor E, Perez A, Taylor C, on behalf of
the Guideline Development Group. Diagnosis and management of
attention-deficit/hyperactivity disorder in children, young people, and
adults: summary of NICE guidance. BMJ 2008;337:a1239. (24 September.)[Free Full Text]

Santosh P, Taylor E, Swanson J, et al. Refining the
diagnoses of inattention and overactivity syndromes: A reanalysis of the
Multimodal Treatment study of attention deficit hyperactivity disorder (ADHD)
based on ICD-10 criteria for hyperkinetic disorder. Clin Neurosci Res
2005;5:307-14.[CrossRef]

Swanson JM, Hinshaw SP, Arnold LE, et al. Secondary
evaluations of MTA 36-month outcomes: propensity score and growth mixture
model analyses. J Am Acad Child Adolesc Psychiat 2007;46:1003-14.[CrossRef][ISI][Medline]

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Diagnosis and management of attention-deficit/hyperactivity
disorder in children, young people, and adults: summary of NICE
guidance

Tim Kendall, Eric Taylor, Alejandra Perez, Clare Taylor on behalf of the
Guideline Development Group
BMJ 2008 337: a1239. [Extract]
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