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[15 November 2012] - If asked to think about drug use among children, most of us would probably call to mind the illicit kind. Less readily thought of, but of equal concern, is the problem of children being put on drugs unnecessarily – and by people in positions of trust. This issue has gained increasing media attention in recent years, especially in relation to the treatment of behavioural difficulties such as Attention Deficit Hyperactivity Disorder (ADHD).
Children’s right to the highest attainable standard of health, as enshrined in the Convention on the Rights of the Child, not only includes access to medical care, but access to the appropriate kind of assistance, be it medical, psychological or otherwise. But in the case of treatment received by children affected by ADHD, interventions to-date have been riddled with controversy.
Children and adolescents – and even infants – diagnosed with ADHD or other behavioural difficulties are being routinely given powerful prescription drugs, sometimes in combination with others, often unnecessarily, and at an increasingly young age. Sadly, finding ever cheaper and easier ways to keep children “under control” all too often takes precedence over considering the long- and short-term effects of such an approach to treatment. This week, CRIN looks at this situation in more detail.
What seems to be the problem?
For over 60 years, methylphenidate hydrochloride – or Ritalin, by its commercial name – which has the same pharmaceutical profile as cocaine (although one study found it to have a more potent effect on the brain), has been used to calm hyperactive children. But for over a decade, professionals have called into question the safety of, and need for, Ritalin and other similar drugs such as Adderall or Concerta, when used on children diagnosed with ADHD.
ADHD is estimated to affect between three per cent and 10 per cent of school-aged children, with figures varying between countries. Those affected have difficulty paying attention, which often causes them to fail at school. Other effects such as restlessness, impulsiveness and disruptive behaviour can even lead to their suspension or expulsion. ADHD can also make people aggressive, which in the case of children causes problems both in the classroom and at home, and can also present a barrier to forming friendships.
In some cases, parents claim Ritalin has transformed their children for the better, improving their behaviour both at home and in school. However other parents condemn Ritalin for having aggravated the disorder, as well as turning their children into “zombies” and addicts, with some parents reporting “terrible” withdrawal symptoms. There have also been cases where medication to treat ADHD has induced temporary psychosis, depression and suicidal thoughts. Presumably this is why prescriptions for Ritalin are sometimes accompanied by antidepressants. One study has also shown that children taking Ritalin suffer stunted growth.
The use of drugs to treat ADHD has also been suggested as a cause of death among a number of its users. In 2006, US experts recommended that Ritalin should carry the highest-level warning that it may increase the risk of death from heart attacks, after the deaths of 51 children and adults in the US since 1999. The United Kingdom's medicine licensing authority, the Medicines and Healthcare Products Regulatory Agency (MHRA), has said that methylphenidate "is recognised to cause cardiovascular adverse effects", including a racing or abnormal heartbeat, palpitations and increased blood pressure. Also in 2006, the MHRA revealed that nine children had died in the UK among a smaller population on the medication. Among them, two died from haemorrhaging and swelling in the brain, two others from heart-related problems, and another two committed suicide.
A worrying increase
Despite these concerns, professional associations have reported a considerable increase in the number of children diagnosed with behavioural difficulties being prescribed powerful drugs and sometimes in conjunction with antidepressants. But it is unclear what long-term effects these cocktails of drugs will have on children whose brains are still developing. This problem highlights the need for control in the excessive diagnosis of the condition.
Opponents to the diagnosis of ADHD claim that some UK doctors are now dishing the pills out "like smarties". Prescriptions for drugs to treat ADHD in England almost doubled between 1998 and 2004. But by 2010 they had increased fourfold, from 158,000 in 1999 to 661,463 in 2010, according to figures released by the NHS business services authority. In 2009, 30 per cent of children in Uruguay were consuming methylphenidate according to the Ministry of Public Health, which prompted a court to order that the Government tighten controls on its importation and supply.
Yet of concern is not only the increase in the number children being prescribed medication, but also the increasingly younger age at which they are put on drugs, in some cases some are as young as 18 months. The Association of Educational Psychologists in the UK has said it believes guidelines set out by the National Institute for Health and Clinical Excellence, which stipulates that preschool children should not be prescribed ADHD drugs, are not being followed.
Making the right diagnosis
But before a child is prescribed medication comes the diagnosis. The problem of over-diagnosis is significant. For instance, there are more adults in the US taking anti-depressants like Prozac and Zoloft than the National Institute of Mental Health estimates there are depressed people. And this concern can also be extended to the number of children diagnosed with, and prescribed medication for, ADHD.
There are concerns that using drugs to treat children who present symptoms of ADHD can mask other, often emotional, causes of troubled behaviour. Psychiatrists, for example, have highlighted that tantrums can be mistaken for more serious disorders. Some, such as Dr Gwynedd Lloyd from the University of Edinburgh, do not even acknowledge ADHD as a medical condition, as it is diagnosed through a behavioural checklist, and not through medical procedures like a blood test. She says that when children show signs of behavioural difficulties, “some of these are [indeed] biological, but most are social and cultural.”
Children as the new target market
Doctors in the United States wrote three million prescriptions for ADHD every month in 2006. One million for adults, and two million for children. By 2010, the sale of Ritalin had increased 83 percent. Today, four million children are taking Ritalin. Indeed, in some places, children's use of prescription drugs has grown faster than any other age group in recent years, with some reports saying that they are the “new frontier for sales”. And as more children are diagnosed with ADHD than adults, pharmaceutical companies are paying attention.
Ritalin was first used in the 1950s to treat depression, but its potential to calm hyperactive children emerged a decade later. And one of the reasons why an exponentially growing number of children are prescribed the drug is simple marketing. Drug companies have honed in on a niche in the pharmaceutical industry, which has opened the door to an entirely new – and profitable – market: children. Some professionals note that drug companies spend considerable amounts of money on elaborate campaigns to make the public believe that ADHD can be treated by a miracle pill.
Advertising with images of smiling children and happy parents perpetuate this idea. “And underneath, it says something like, 'They're happy, because now they know his ADHD is being treated,'” notes child psychiatrist Peter Jensen. “What's the problem with that?” he continues. “The problem is it pushes people to only one way of thinking about the problem--that this is a biological problem, and that it needs a drug.” And although the work of drug companies is guided by science, Jensen highlights that “it's not the only science.” But he also recognises that research on alternative therapies does not have the same lobbying power as drug companies: “If people could demonstrate clear effectiveness from the treatments that didn't involve medication, I think that there would be a lot of people beating a path to their door. The fact is that they haven't been able to demonstrate that.”
Part of the problem, however, is that since the 1980s when ADHD was first classed as a medical condition, it has since been represented as a “brain disease”, according to child neurologist and active opponent to the diagnosis of ADHD Fred Baughman. This perception has made it “logical for the public to think that a pill is going to be the solution,” which he adds, “is to deceive the public [as] it preempts [their] right to informed consent in every single case.”
This issue not only involves the provision of appropriate information – both on medical as well as alternative treatments – but also adequate access to it. Doctors’ and parents’ decision to treat a child apparently affected by ADHD should not be based on the influence of large marketing campaigns; a child’s best interests – as determined in each single case – should be considered above all else. Ultimately for drug companies, however, it comes down to a money-making scheme. As psychiatrist Peter Breggin observes:
“The drug companies, like the tobacco industry, like the alcohol industry, are highly competitive, and are always searching out new markets. The adult market has been saturated for anti-depressant drugs. How many millions and millions of people can take Prozac and Zoloft and all the other drugs? ...[S]o the pressures move automatically to other markets. And the biggest next market is children. So you have drug company representatives, you have drug company-sponsored conferences examining this issue, or encouraging this issue of marketing to children.”
And according to Dr Gwynedd Lloyd from the University of Edinburgh, the sudden increase of ADHD diagnoses in the mid-1990s in the UK corresponded with a rise in marketing from US pharmaceutical companies, which felt they had saturated the American market.
Only as last line of treatment
As a drug, Ritalin and similar drugs have potential side effects, so experts agree that it should be resorted to as a last measure. They say that the first line of action must be non-drug-based alternatives, including behavioural therapy, special diets, and spending more time in an outdoor and preferably rural environment. In the more severe cases in which alternative treatments fail, there arises the question of who should be allowed to prescribe medication, and whether it should be used exclusively or form part of more comprehensive treatment.
The problem is that the drugs used to treat ADHD address the symptoms, but do not help the affected child to handle the condition in a sustainable way that does not encourage dependency on medication. As Dr Tim Kendall of the UK's Royal College of Psychiatrists emphasises, “the important thing is we have a comprehensive approach that doesn't focus on just one type of treatment.”
Guidance issued by the UK's National Institute for Health and Clinical Excellence (NICE) say that drugs, where they are given, must be used alongside psychological therapy and support. And that once young people using ADHD drugs stabilise, the drug should be withdrawn. Controversially, however, NICE also rules out special diets, such as those that include omega 3 fish oils, despite some researchers suggesting otherwise.
One alternative treatment that could help combat ADHD is spending more time in a natural environment. A report commissioned by the UK's Royal Society for the Protection of Birds called 'NaturalThinking' suggests that activities in green spaces appear to improve children's symptoms by 30 per cent compared with outdoor activities in urban areas, and threefold compared to playing indoors.
But Liberal Democrat MP Tessa Munt said many young people are unable to enjoying the outdoors for several reasons including a lack of school playing fields and the popularity of electronic devices such as video games and smartphones as well as social networking sites. The experience of a former teacher supports this arguement:
“Teachers would say 'sit still!' Kids need to run around and do things to keep their energy sated - I know I did. It's obviously cheaper to medicate people than to have a society that allows them space and time to run, play, or to think for themselves. [As a teacher] I couldn't easily [plan to take my students on trips] because I needed parental permission just to get students out of class. We live in a litigious society, where it's easier to medicate than to walk outside.”
But as noted earlier, research on alternative therapies have considerably less marketing presence than pharmaceutical companies.
Then there is the question of who should be allowed to prescribe drugs to treat ADHD. International regulations stipulate that only medical professionals (psychiatrists, in collaboration with a multi-disciplinary team), rather than paediatricians or general practitioners, may intervene in cases of suspected ADHD. In the UK, GPs must refer the patient to a specialist with expertise in ADHD before the initial prescription can be given. But professional associations have noted that many specialists do not follow recommendations set out by NICE, such as by signing off the medication before checking if ADHD behaviour is exhibited at both at school and at home.
The number of prescriptions for ADHD drugs continues to rise in spite of the fact that adverse effects to the medication prescribed, some fatal, have been recorded. Acknowledging this, experts agree that physicians should be made aware of the concerns evidenced by side effects, as should parents, who must also be informed of all possible reactions a child might have. One member of the Food and Drug Administration in the US said in a 2007 interview that he hoped health concerns related to the use of Ritalin might reduce the number of prescriptions to treat children who are inattentive or who misbehave in school. "I want to get people's hands to tremble a little bit before they write that [prescription]," said Dr Steven Nissen.
Inevitable compromise
Academics have also raised the concern that some schoolsteachers are encouraging the use of drugs to treat apparent ADHD as it is an easier alternative to dealing with bad behaviour. In the worst cases, schools have been known to put significant pressure on students and their parents to seek the medication. In one case, a schoolboy diagnosed with ADHD was told that if he did not go on Ritalin and act with more respect, he would have to leave the school.
But the problem is also one of resources, as schools often lack the necessary means to get to the root of disruptive behaviour. “Ideally,” says an assistant head teacher in the UK, “schools would prefer to offer intensive one-to-one support, but if the resources are limited – which they usually are – then we're pushed into a choice between medication or exclusion.” And in the current economic climate, “all schools are facing cuts and it may well be these sorts of services – therapists, counsellors, mentors – that will be the targets because, understandably, schools don't want to lose teachers.”
Drawing on the testimony of a 13-year-old boy, "I know it helps me in some ways, but I hate taking it. There are days when I deliberately avoid it. You just don't feel yourself, you feel so drained out. It makes you feel disgusted and down. Like you've got no soul or something. My mum doesn't want me to take it, but what can she do? She wants me to get an education."
The Last Word
“Our children are living in the most intensely stimulating period in the history of Earth. They’re being besieged with information and calls for attention from every platform: [from] computers, from iPhones, from advertising hoardings, from hundreds of television channels. And we’re penalising them now for getting distracted. From what? Boring stuff - at school - for the most part. It seems to me, if not a coincidence, [then] totally, that the incidence of ADHD has risen in parallel with the growth in standardised testing. Now these kids are being given…often quite dangerous drugs to get them focused and calm them down.”
– Educationalist Sir Ken Robinson on the need to change current education paradigms.