ADHD treatment in Latin America and the Caribbean
Letter to the Editor
To the Editor:
Attention-deficit/hyperactivity disorder (ADHD) is one of the most prevalent mental disorders of childhood and has been a major focus of scientific attention in the past few decades.1 A wide range of empirical data support the validity of the disorder, its associated burden,1 and its worldwide distribution.2 However, uncertainties remain about the rate of treatment around the world. In the United States, it is estimated that approximately 56% of children with a reported diagnosis of ADHD have been treated with medication.1 The rate of treatment in developing countries is expected to be much lower than in developed countries due to inadequate health care systems, lack of human resources, and poor knowledge of the population with the disorder.3 Community data on the rate of children with ADHD on treatment around the world have the potential to identify cultural and/or economic barriers to treatment and to guide efforts and resources to overcome them. Thus, we performed an electronic review with the goal of identifying studies with nonreferred samples from the community that have evaluated the prevalence of children with ADHD treated with stimulants in Latin America and the Caribbean.
We searched Medline through PubMed with the keywords ADHD and therapy, therapeutics, pharmaceutical preparations, medication, stimulant, methylphenidate, Latin America, and Caribbean and for each of the 46 countries from Latin America and the Caribbean according to the Economic Commission for Latin America. This review yielded 92 abstracts, and only one study that specifically covered the issue.4 Furthermore, we were aware of three studies that evaluated nonreferred children and adolescents from the community for ADHD and that, as a secondary measure, assessed the number of children on stimulants.5-7 The results of these four studies are reported here.
In Puerto Rico, Bauermeister et al.4 evaluated a probability household sample of 1,897 children ages 4 to 17 years. Among those children diagnosed with ADHD by the researchers, 7.0% had received stimulants during the previous year, and only 3.6% were receiving stimulants at the time of the interview. In Venezuela, Montiel-Nava et al.5 evaluated a probability school-based sample of 1,535 individuals ages 4 to 12 years. The rate of stimulant treatment among children diagnosed with ADHD was 4.0%. In Brazil, Schmitz et al.6 ascertained more than 400 nonreferred school children ages 6 to 18 years who screened positive for ADHD and identified 100 individuals with ADHD inattentive subtype. Among those children with ADHD, only 3.0% were taking stimulants at the time of diagnosis. Szobot et al.,7 also in Brazil, evaluated 968 male adolescents ages 15 to 20 years for substance use disorder and ADHD. Among those adolescents with ADHD, or even (and perhaps more relevant) those with ADHD and substance use disorder, none were taking or had ever received stimulants during their lifetime.
The Economic Commission for Latin America estimates an overall population of more than 576,000 million people in Latin America and the Caribbean in 2007, and children and adolescents younger than 15 years of age represent approximately 30% of the population. Assuming that ADHD affects 5.0% of children worldwide2 and that no more than 4.0% of children diagnosed with ADHD are treated with stimulants in Latin America and the Caribbean, we would estimate that more than 8 million children with ADHD are undertreated and underdiagnosed in this region of the world. It is possible that some of these children received psychosocial treatment rather than medication (from 13% to 23% with ADHD in Puerto Rico).4 However, the type of psychosocial treatment used in community settings is frequently not empirically supported and the existing resources for effective behavioral treatment for ADHD in these countries are scarce.3 We detected a complete absence of national surveys concerning children's mental health in Latin American and Caribbean countries and were able to find studies that generated evidence pertaining to specific populations in only three of 46 countries. The existing data indicate that children and adolescents with ADHD are undertreated in Latin America and the Caribbean. There is an urgent need for consistent policies on children's mental health, for which the empirical evaluation of clinical practices is a prerequisite.
Disclosure: The ADHD Outpatient Program receives research support from the following pharmaceutical companies: Bristol-Myers Squibb, Eli Lilly, Janssen-Cilag, and Novartis. Dr. Rohde is on the speakers' bureaus of or is a consultant to the same companies and is on the advisory board of Eli Lilly. Dr. Bauermeister is a member of the Eli Lilly advisory board. Dr. Szobot is on the speakers' bureau of Janssen-Cilag and has received travel support from Novartis. Dr. Schmitz is on the speakers' bureaus of Novartis and Janssen-Cilag. Drs. Polanczyk and Montiel-Nava report no conflicts of interest.
Polanczyk, G., Rohde, L. A., Szobot, C., Schmitz, M., Montiel-Nava, C., & Bauermeister, J. J. (2008). ADHD TREATMENT IN LATIN AMERICA AND THE CARIBBEAN. Journal of the American Academy of Child & Adolescent Psychiatry, 47(6), 721–722. https://doi.org/10.1097/CHI.0b013e31816c0008
Journal of the American Academy of Child & Adolescent Psychiatry