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Disordered thinking?

The prescribing of ADHD drugs is soaring, while concerns are escalating about damaging side effects. Is it time that the social and family lives of ADHD-diagnosed children are examined as much as their brains, asks Adam James

February 14, 2006

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If you're sceptical about the wisdom of the soaring prescription rate of drugs for ADHD-diagnosed children, you can place some of the blame for zealous prescribing at the hands of the National Institute for Health And Clinical Excellence (Nice).

Back in 2000 the treatment advisory body gave psychiatrists and pediatricians the green light to prescribe methylphenidate drugs such as Ritalin and Concerta to ADHD-diagnosed children without any obligation to reflect on how that child’s family or social environment may underpin the child's behaviour

On one hand Nice's guidelines on methylphenidate did recognise that “a comprehensive treatment programme [for ADHD] should involve advice and support to parents and teachers". But, on the other, the guidelines added: "While this wider service is desirable, any shortfall in its provision should not be used as a reason for delaying the appropriate use of medication.”

Nice's message is clear. It's acceptable to prescribe a nine-year-old with psychostimulant medication without needing to insist on any meaningful support or education for the child’s family or teachers. So, if that nine-year-old’s disadvantaged, unemployed, fraught parents are forever at each other’s throats or the child is getting routinely beaten up by bullies behind the school bike shed then fear not - no intervention can, or need be, enforced in combination with medication. Nice’s message is to home in on the child’s brains, not, for example, the child's bullies.

And the rush to prescribe ADHD-diagnosed children with methylphenidate ADHD drugs, such as Ritalin and Concerta, is unrelenting. This month’s Nice draft scope guidelines on how best to treat ADHD-diagnosed children reported that the prescribing of ADHD drugs almost doubled between 1998 and 2004. Around 420,000 prescriptions were made in 2004.

There's much testimony, as well as evidence, purporting to back the effectiveness of ADHD medication. But what of the effectiveness of other interventions for ADHD-diagnosed children whose impulsiveness, hyperactivity, and restlessness could – as many researchers argue - be linked to family/socio-economic factors (such as abuse or poverty) as much as, for example, “deficient neuronal inhibition”? What about exploring family dynamics? What about helping mum or dad control their aggressive outbursts? What about boosting a youngster’s self-esteem? What about stopping the youngster from getting beaten by a drunken uncle? Such “psychosocial” or support interventions are available. There's the Family Well-Being Project in Birmingham, or the Parent Adviser Scheme scheme in Tower Hamlets, London, or the Sutton Hill Families Project in Telford.

Are they successful? Yes, say the practitioners. But, as GP Raja Bandak wrote in the book, Making and Breaking Children’s Lives, published last year, no random controlled studies have evaluated family support for ADHD children. And without such objective “evidence-base”, will Nice ever have the justification to give family support the same weight of importance as medication?

Until now, it has been families with designed-in-a-bedroom websites, such as ritalindeath.com, which have been most energetic in trying to warn professionals about fatal effects of, for example, Ritalin. But the debate around ADHD drug safety heated up last week after advisors to the US drug regulator, the Food and Drugs Administration, recommended that “black box” warnings be issued on ADHD drugs. Figures show that 52 people have died in the US after taking methylphenidate or amphetamine ADHD drugs.

In the meantime, nine children on methylphenidate drugs have died in the UK, and it’s likely that the UK’s drug licensing body, the Medicines and Healthcare Products Regulatory Agency, is to feel pressure to examine more closely the possible damaging long term effects of ADHD drugs. It seems puzzling that, while the MHRA recommends against SSRI antidepressants being prescribed to under 18s, psychostimulants - with chemical properties similar to cocaine – can be given to a five-year-old

Nice last month began its long deliberations on drawing up clinical guidelines for doctors and other professionals on how best to treat/support ADHD-diagnosed children. A first meeting is to be held in March. Will non-pharmacological interventions have a level playing field with pharmaceutical firm backed drug treatments? For reasons outlined above, probably not. Infact, Nice’s draft clinical guidelines scope has already hinted at a preference to refer to the biology – as opposed to the experience - of ADHD-diagnosed children. The scope states that "various genetic and environmental risk factors for ADHD have been identified” and that “hereditary aspects, neuroimaging data and responses to pharmacotherapeutic agents support the suggestion that ADHD has a biological component”. Here it is again - the green light for psychostimulant prescribing without the requirement to examine, with resource-backed commitment, the lives of ADHD children.

Interestingly, however, Nice’s scope also states there “is a continuing debate over the causes of ADHD”. Exactly. And, if so, then possible abuse, bullying, or room-for-improvement parenting underpinning the behaviour of impulsive, hyperactive, disturbed children should surely be "treated" as much as their brains.

The National Institute for Health and Clinical Excellence's draft scope for clinical guidelines on ADHD (pdf)
The National Institute for Health and Clinical Excellence's guidelines on methylphenidate (pdf)

Adam James is editor of psychminded.co.uk

See also:
Feb 14, 2006: ADHD drugs should carry heart attack warning, US scientists recommend - pressure on UK drug regulator to issue similar warning likely to mount.

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