Research Article: Packages of Care for Attention-Deficit Hyperactivity Disorder in Low- and Middle-Income Countries

Date Published: February 23, 2010

Publisher: Public Library of Science

Author(s): Alan J. Flisher, Katherine Sorsdahl, Sean Hatherill, Sonia Chehil

Abstract: In the sixth in a series of six articles on packages of care for mental disorders in low- and middle-income countries, Alan Flisher and colleagues discuss the treatment of attention-deficit hyperactivity disorder.

Partial Text: Attention-deficit hyperactivity disorder (AD/HD) is a chronic, pervasive developmental disorder that, although usually diagnosed in childhood, spans the preschool to adult years. The most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) defines the disorder using the core features of age-inappropriate hyperactivity, impulsivity, and inattention (Box 1) [1]. The 10th edition of the International Classification of Diseases (ICD-10) provides operational criteria for the similar, but more severe and narrowly defined hyperkinetic disorder (HKD) [2]. We have used the term AD/HD throughout this paper because most of the published literature relates to the broader concept of AD/HD rather than to HKD.

AD/HD is a common developmental disorder that affects individuals throughout their lives and across all cultural contexts, and is associated with considerable social, psychological, and economic adversity. Recognition of the disorder can be improved by the use of screening instruments, some of which have been shown to have adequate psychometric properties in LMICs. Although there are few studies from LMICs that address the effectiveness of methylphenidate, the consistent and strong effects that have emerged from HICs suggest that this drug will be effective universally. In addition, although the evidence for structured psychotherapies is mixed, there is sufficient justification to include behavioral interventions in a package of care for AD/HD in LMICs (Table 3). However, given that most people worldwide with AD/HD will not receive interventions from a mental health specialist such as a psychiatrist or psychologist, it is essential that efforts to deliver this package of care in LMICs are not dependent on such specialists. There are risks associated with such an approach. For example, the quality of the interventions may be less than would have been the case if they were delivered by specialists. However, such risks need to be weighed against the certainty that services will be less accessible if they are delivered by specialists. Finally, it is crucial that this package of care for AD/HD form part of a more comprehensive package of services in which other disorders are also addressed.



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