Reply to L. Reale et al. “More and better should be done to guarantee evidence-based management of ADHD in children across Europe”


Dear Editor We appreciate the interest shown by L. Reale et al. in our recent publication on the management of ADHD in children across Europe [1]. We fully agree with the authors that patients should be managed according to the best available levels of both evidence and treatment, and indeed, this was the motivation for undertaking our study to examine the similarities and differences in real-world management of ADHD in Europe. We acknowledge the limitations of a retrospective study design and clearly discuss these in our paper. The imbalances observed within and between countries demonstrate that a clear, consistent approach to diagnosis and treatment of ADHD is lacking. The use of tools other than DSM-IV or ICD 9/10 for diagnosis in clinical practice highlights the need for diagnostic methods to be standardized across Europe, as the physicians sampled in this study have, in general, large practices and many years of experience. With regard to starting therapy, data on up to five previous treatments were collected in the study, working back from the time of chart abstraction. Only seven patients in our sample (about 1 %) had five or more lines of treatment, so we believe that our data set does include starting therapy information in the majority (99 %) of the study population. As we note in our paper, it is not possible to ascertain whether medication was optimally titrated, which is why we consider that it is important to evaluate further the treatment data in subsequent research studies. In our view, this research, along with other published studies [2], highlights the fact that evidence-based interventions are not always applied by treating physicians, and that, for example, prevalence rates of diagnosed ADHD patients may easily be influenced by the use of different diagnostic tools. Reale et al. also comment that as “only 34.5 % of patients were being treated with combination therapy in accordance with National Institute for Health and Care Excellence (NICE) guidelines [3], only 30.8 % of patients would be expected to show ‘complete symptom control’.” As they have already noted, our study data were collected in 2009 and relate to patients first diagnosed between 2004 and 2007, prior to the publication of the current NICE guidelines, so we would not necessarily expect participating physicians to be following this guidance. It must also be accepted that whilst NICE guidelines provide the expert opinion of optimal ways to support individuals with ADHD, they certainly do not suggest that using these methods will result in “complete symptom control” for all. Our data show a snapshot of current treatment practice at the time of chart abstraction, in a real-world setting. More patients than shown in this snapshot will have received combination therapy at some point during their treatment Debanjali Mitra: affiliation at the time this workwas done and the original article was published P. Hodgkins (*) : J. Setyawan Shire Development, LLC, Wayne, PA, USA e-mail:

DOI: 10.1007/s00431-013-2185-2

Cite this paper

@article{Hodgkins2013ReplyTL, title={Reply to L. Reale et al. “More and better should be done to guarantee evidence-based management of ADHD in children across Europe”}, author={Paul S. Hodgkins and Juliana Setyawan and Debanjali Mitra and Keith L. Davis and Javier Quintero and Moshe Fridman and Monica Shaw and Valerie Harpin}, journal={European Journal of Pediatrics}, year={2013}, volume={173}, pages={551-552} }