Children
with attention deficit hyperactivity disorder (ADHD) should be treated
with drugs such as Ritalin only in severe cases and never when they are
younger than 5, under official health guidelines issued today.
Widespread
concerns that medication is used too freely to calm hyperactive
children have been recognised by two clinical practice watchdogs, which
are now advising doctors not to prescribe drugs whenever possible.
Most
children with ADHD should instead be offered psychological therapy to
improve their behaviour, backed up by training to support their parents
and teachers, the National Institute for Health and Clinical Excellence
(NICE) and the National Collaborating Centre for Mental Health (NCCMH)
recommend.
Drugs such as Ritalin and Concerta (brand names for
methylphenidate) and Strattera (atomoxetine) should be used as
frontline treatments only when severe ADHD is diagnosed, or when other
options have failed.
While up to 3 per cent of school-age
children in Britain are affected by ADHD, only about a third to a
quarter of these would qualify as severe cases. In a typical school of
1,400 children, between 30 and 40 would have a diagnosis of ADHD, and
about 10 would be classed as severely affected.
The symptoms of
ADHD include an inability to concentrate for long periods, hyperactive
and restless behaviour, and impulsive actions, such as speaking without
thinking of the consequences or failing to wait and take turns. It also
affects about 2 per cent of adults.
ADHD support groups welcomed
the guidelines, but said that they would have to be backed by increased
resources for behavioural therapy if they are to have the desired
effect.
Andrea Benbow, chief executive of the Attention Deficit
Disorder Information and Support Service, said that many parents had to
wait months or even years to be given psychological therapy and
training, and that many programmes were not designed for ADHD or
effective for it.
“There are huge waiting lists, and many
training programmes are not ADHD-specific and they're useless,” she
said. “We need these interventions - drugs are not the be all and end
all - and parents would welcome them if they were there.
“This
needs to be backed by better resources. Lots of the good programmes are
delivered by the voluntary sector, but the problem is, who funds them?”
The
new guidance follows growing disquiet among some parents, teachers and
doctors about the number of children taking medication for ADHD, who
often remain on drugs for years.
More than 600,000 prescriptions
for the three drugs were filled in 2007 in England, though the number
of children who received them is estimated at between 50,000 and
100,000 because only a month's supply is generally prescribed at once.
Ritalin
is the most common ADHD drug, with 461,000 prescriptions filled in
England in 2007. This compares with 199,000 in 2003, 26,500 in 1998 and
3,500 in 1993. The growth has alarmed some observers, concerned that
some doctors are turning to medication too quickly to control a
disorder that often responds well to other treatment strategies.
Ritalin
and Concerta can have side-effects that include nervousness, insomnia,
appetite loss and weight loss. Strattera can cause nausea, dizziness,
fatigue and mood swings. There has also been little research into the
implications of taking them as long-term treatments.
Prescription
rates vary widely. In July a study by the Health Service Journal found
that some primary care trusts offer Ritalin up to 23 times more than
others: in Wirral, pharmacists dispensed one prescription for every
seven children under 16, compared with one for every 159 children in
Stoke-on-Trent.
Other treatment options include sending children
on courses of cognitive behavioural therapy or social skills training,
and training parents in how to cope with the condition and improve
their children's behaviour. Teachers can also be trained to manage
children with ADHD.
These can be highly effective, but drugs are
often used instead because they offer a quicker solution and are not
subject to long waiting lists.
The guidelines recommend a sparing
approach to drug use when possible. Tim Kendall, a consultant
psychiatrist in Sheffield and joint director of the NCCMH, who sat on
the expert panel, said: “Quite commonly, people tend to revert to
offering methylphenidate or atomoxetine.
“When they do that, it's
not always because there's a good balance of risk and benefits. It's
because the child has got what appears to be ADHD and that's what's
available. It's easier to prescribe a drug when other options like
parent-training programmes are not available.”
Gillian Leng,
deputy chief executive of NICE, said: “Today's guideline, which is
published during ADHD Awareness Week, is the first guideline to address
the diagnosis and management of ADHD within both clinical and education
settings. At its heart is the recognition of the importance of
establishing a multidisciplinary team, including the person with ADHD,
their family and their teachers in order to help support the person
with ADHD achieve their full potential.”
Professor Eric Taylor,
of the Institute of Psychiatry in London and chairman of the guideline
development group, said: “I believe these guidelines will make people
with ADHD, and their families, more confident that their problems will
be recognised and can often be helped, and that they will provide
professionals with a framework for good practice nationally.”
