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What is the impact of ADHD and its management on quality of life (QoL) of children?
Quality of life (QoL) as assessed by the parent or child/adolescent using any instrument. The included studies used mainly generic instruments including: the Child Health Questionnaire, Pediatric Quality of Life Inventory, Youth Quality of Life Instrument-Research Version, the Munich Quality of Life Questionnaire for Children, the Dutch Child AZL TNO Quality of Life, the TNO AZL Child Quality of Life, the EuroQoL Five-Dimension Questionnaire, standard gamble interviews and the Global Impression of Perceived Difficulties. The only disorder-specific measure used was the ADHD Impact Module.
Ovid MEDLINE (R), Cochrane database of systematic reviews, ACP Journal Club, DARE, CCTR, CMR, HTA, NHSEED, EMBASE and PsychINFO were searched for the period between 1988 and April 2008. Hand-searches of reference lists of identified papers and reviews was also carried out.
Study selection and analysis:
Studies published in peer-reviewed journals providing empirical data on the QoL of children or adolescents with ADHD were included. All abstracts and the full texts of the selected papers were assessed by two authors. Data were extracted by one author and checked by two other authors. Results of the studies were summarized narratively. An effect size of at least half a SD was required to be considered as a clinically meaningful difference.
A total of 36 studies met inclusion criteria. Most studies only included parent ratings of child quality of life (29 studies), with five studies using both parent and child/adolescent ratings and two studies using only child/adolescent ratings of QoL. Another 27 studies assessed the impact of ADHD on QoL, with 25 of them using clinical samples of referred children. A total of 19 studies used a cross-sectional design (including four studies using baseline data from RCTs), 8 used a case–control design (including one study that followed this up with an open-label trial of methylphenidate), and 1 study was longitudinal. Parents reported reductions of around 1.5 to 2.0 SDs in quality of life measured using different instruments and across different domains. Children tended to rate their QoL more positively than parents. Children with ADHD did not always report themselves as functioning less well than healthy controls. Fourteen studies assessed the effect of ADHD treatment on quality of life (two methylphenidate, two mixed amphetamine salts, nine atomoxetine, and one, a novel drug). One randomized controlled trial compared the effects of mixed amphetamine salts versus atomoxetine and found similar reductions in QoL. A meta-analysis of three RCTs found that atomoxetine improved psychosocial quality-of-life summary score compared with placebo (d=0.55, p=0.0001), but not physical summary score (d=-0.11, p>0.05). An independent meta-regression analysis of nine RCTs found that atomoxetine improved psychosocial summary score in treatment group, compared with placebo (SMD 0.47, 95% CI 0.25 to 0.69).
Available studies support that ADHD impairs QoL in children and young people. These effects are greatest with parent ratings rather than child/young person ratings of quality of life.
Although current ADHD literature and clinical practice focus mostly on observable behavioural core symptoms, the subjectively perceived QoL has the potential to become an extremely important issue.
From a scientific standpoint, including measures of QoL may result in a more broadly contextualized understanding of the causes and consequences of ADHD. In clinical practice, taking QoL into account can allow us to better integrate the child's perspective into clinical management. From a public health standpoint, QoL could indicate to what extent ADHD health needs are met, thus increasing the scope for a more evidence-based resource allocation.
Therefore, the rationale and the implication of this comprehensive and methodologically sound review are straightforward. Using a rigorous search strategy, Danckaerts and colleagues retained a quite limited number of pertinent studies (36). Moreover, given the variety of QoL measures, it was not possible to combine the study results into a meta-analysis. Therefore, further studies and standardized measures of QoL are necessary.
A major finding of the review was that, though the parents consistently indicated significantly lower QoL in ADHD compared to healthy children, the reports by the children themselves were inconsistent. This may be due to a minimization of difficulties by the children and/or to possible methodological issues of the available tools. As proxy informants, while providing useful information, cannot be considered a replacement for the child, research aimed at elucidating this discrepancy is needed.
The authors thoughtfully pointed out other limitations of the ADHD literature, including the lack of studies assessing: (1) the longitudinal course of QoL, (2) the impact of psychoeducational interventions on QoL and (3) the QoL in non-clinical settings. Interestingly, one of the limitations outlined in the review, the lack of controlled studies evaluating the impact of methylphenidate on QoL, has been addressed in some reports published after the review. Moreover, some issues not discussed in the paper, such as the QoL of ADHD adults and that of the family of ADHD children, have begun to be addressed in recent studies. However, although the field is moving, further evidence-based research is necessary before considering QoL as the “gold standard” against which other health outcomes should be assessed in ADHD.
Sources of funding This paper was derived from a work group meeting of the European ADHD guidelines group. The meeting costs were supported by Elli Lilly, Janssen-Cilag, and Novartis and Shire.
Competing interests SC has received financial support to attend medical meetings from Eli Lilly & Company and Shire Pharmaceuticals, and has been co-investigator in studies sponsored by GlaxoSmithKline, Eli Lilly & Company, and Genopharm. He serves as a consultant for Shire Pharmaceuticals.
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