HANSARD - Tuesday July 12th 2011 -ASKING QUESTIONS OF THE HEALTH MINISTER IN THE HOUSE - WHY ARE THERE NO UP TO DATE STATISTICS FOR CHILDREN UNDER THE AGE OF SIX BEING PRESCRIBED METHYLPHENIDATE WHEN IT IS CLEARLY AGAINST NICE GUIDELINES?"

Mr Pat McFadden MP:

The Secretary of State will be aware that there has been a tripling of prescriptions for drugs such as Ritalin, or to give it its generic name methylphenidate hydrochloride, in the past decade. He will also know that NICE guidelines state that those drugs should not be prescribed to children under the age of six. Why cannot his Department give a breakdown showing how many of those prescriptions are going to children under the age of six? Will he heed the call from the Association of Educational Psychologists for a review of the growth of the prescription of those powerful psycho-stimulants to very young children?

Paul Burstow(Lib-Dem)-Secretary of State for Care:

The Right Hon. Gentleman raises a very important point. We need to ensure that we have the right data to properly understand prescribing practice, so that we can both challenge bad practice and ensure that the NICE guidance is properly followed. I would like to look more closely at his points and then write to him in detail.

PREVIOUS WRITTEN QUESTIONS TO SECRETARY OF STATE FOR HEALTH - FROM PAT McFADDEN -MP. and REPLY FROM MINISTER.(JULY 6TH 2011)

(1) if he will estimate the number of children who have been prescribed Ritalin or a similar drug;

(2) if he will estimate the number of children under the age of six who have been prescribed Ritalin or a similar drug; and if he will assess trends in the number of such prescriptions in the last five years;

(3) if he will estimate the number of children under the age of six in Wolverhampton who have been prescribed Ritalin or a similar drug;

(4) what guidance (a) his Department and (b) the National Institute for Health and Clinical Excellence issues to practitioners on the prescription of Ritalin and similar drugs to young children.

Anne Milton: I refer the right hon. Member to the answer I gave the right hon. Member for Birkenhead (Mr Field) on 4 April 2011, Official Report, column 684W.

The Information Centre Prescribing Team has advised that this information is not available for children's prescriptions. They have however provided information on the numbers of all Ritalin prescriptions dispensed in the community as follows:

Ritalin is a branded version of the drug Methylphenidate Hydrochloride. The following table shows the total number of items dispensed for Methylphenidate Hydrochloride overall (including Ritalin) and for Ritalin separately for individuals of all ages.

Methylphenidate Hydrochloride prescriptions dispensed in the community in England


Thousand


  

Prescription items


  

Methylphenidate Hydrochloride

  

Of which : Ritalin

1997
  

92.1
  

92.1

1998
  

126.6
  

126.6

1999
  

158.0
  

157.9

2000
  

186.2
  

181.3

2001
  

208.5
  

180.6

2002
  

254.0
  

161.8

2003
  

314.5
  

124.5

2004
  

359.1
  

67.8

2005
  

389.2
  

30.7

2006
  

456.9
  

26.5

2007
  

535.3
  

25.5

2008
  

573.4
  

22.8

2009
  

610.2
  

20.2

Notes:
 

THE DANGERS OF PRESCRIBING TOXIC PSYCHOTROPIC DRUGS FOR INFANTS - DON'T LET US FOLLOW THE U.S. MODEL

  


Do you have any suggestions for treating severe ADHD in very young children (ages 2-4)?

  
Head of the Section of Behavioral Medicine of a State Children's Hospital,  explains the dubious American approach that is not allowed in the U.K.

Pharmacotherapy of ADHD in young children is a dilemma faced by many practicing physicians. Treating young children is poorly understood, even though in recent years it is more widely practiced. At present, clinical practice is hampered by the availability of only a limited number of clinical studies on the effects of stimulants on preschoolers. This problem is compounded by the potential for greater variability of response and the possibility of unanticipated behavioral and cognitive side effects, and thus, it is prudent for physicians to be cautious.

Although early treatment of ADHD tends to yield more favorable outcomes, no gold standard has yet emerged for treatment of preschoolers assumed to have ADHD. One study that addresses diagnosis and treatment of preschoolers with ADHD symptoms indicates considerable variability in procedures. Rappley and colleagues[1] identified 223 children 3 years of age or younger who were diagnosed with ADHD in the Michigan Medicaid system between 1995 and 1996. In all, 44% had problems that coexisted with ADHD, 41% had chronic health conditions, and 40% experienced other injuries. Furthermore, 57% of the sample received psychotropic medication with 22 different medications; only about one quarter (27%) received psychological services. The investigators contended that the scarcity of information on the diagnosis of ADHD in preschoolers and the limited information on efficacy and safety of psychotropic medications for this age group created great variability in the medication regimens.

Psychological consultation or parental education is often recommended as the first line of treatment for families with a preschooler diagnosed with ADHD. Despite this cautious approach, recent studies describe increased stimulant prescribing for American and Canadian preschoolers because of the ease of treatment and availability of prescription remedies.[2] An earlier review by Zito and colleagues[3] showed a notable upsurge (between 1.7- and 3.1-fold) in the use of stimulants for preschoolers in state Medicaid programs. One of the primary reasons cited for the growing use of psychotropic interventions was that many physicians realize that psychological interventions are costly and difficult to sustain. Moreover, medication management is more readily available, easier to administer, and produces consistent results.[4] Despite the increasing use of stimulants for preschoolers with ADHD, efficacy and risk research with young children has been sparse and plagued by sample size problems.[5] The paucity of data and lack of guidelines concerning pharmacotherapy effects in children under age 6 years should be ameliorated by the Preschool ADHD Treatment Study headed by Dr. Lawrence Greenhill, which will develop guidelines for patients aged 4-6 years. Until more information is available, however, clinicians must use practiced knowledge.

Diagnosing and Managing Very Young Children

Severe ADHD in children 2-4 years of age is especially problematic. Young children do not have the ability to use or respond to language to moderate behavior that older children have; subsequently, behavioral interventions often have limited effectiveness. Young children may not make associations between instructions and rules and the consequences of violating them; subsequently, hyperactivity and impulsive behavior are relatively immune to psychosocial intervention.

The younger the child, the lower the certainty of an accurate diagnosis of ADHD. It is very difficult, for example, to diagnose ADHD before age 3 years because short attention span, high activity level, and impulsivity are normal temperamental characteristics at various stages of development (eg, consider the "terrible two's" or the "difficult child" syndrome described in the temperament literature). Such symptoms are not normal, however, when they continue to manifest beyond certain ages.

Symptoms most likely to be associated with ADHD at young ages are chronic motor restlessness; noncompliance; vigorous, persistent activity level; and destructive play. Children may require constant parental monitoring because they show excessive emotional outbursts (ie, tantrums) that are intense and frequent. Such children also often have difficulty completing developmental tasks such as toilet training and sleeping in their own beds, and they may demonstrate delays in motor or language development. Such behavior significantly affects family life as parents have difficulty obtaining and keeping babysitters, and a wife and husband may find their relationship with each other faltering given the constant attention to childcare and behavior control.

Even though diagnosis of mental health disorders in early childhood is problematic, the need for effective treatment of young children is critical. Gadow and colleagues[6] noted that preschool children who were "referred for clinical evaluation evidenced higher levels of symptom severity than a community sample, with children with ADHD symptoms more impaired than other children."

In a naturalistic study of a community sample of young children with ADHD, we examined the quality of behavioral response, and we delineated the side-effect profile of 4- to 5-year-old preschoolers naive to previous psychostimulant treatment.[6] Our preschool sample is not unlike children who might present in typical pediatric practice for treatment of symptoms of ADHD.

The study provides support for the short-term efficacy and safety of psychostimulant medications for preschoolers. Behavioral ratings improved for all children across home and school settings, with 82% of the children receiving clinical ratings of normalized behavior on their optimal dose of medication. In addition, undesirable side effects did not differ from the profile one might see in older children (6-12 years). Many parents reported more side effects during the baseline and placebo weeks than during the best dose week. (This result is reported in other studies as well.[7]) Irritability and diminished appetite are often cited as side effects of stimulant use in young children, but it is important to note that irritability also appears to be a by-product of the disorder itself. Baseline data from our sample indicated that over 33% of preschoolers were rated as irritable by their parents before medical management. These reports are consistent with Connor's review[8] in which he argues that preschoolers benefit from stimulants, side effects appear minimal, but great care should be used in the diagnostic process.

Elimination of behavioral symptoms associated with ADHD in young children, then, can be achieved with medication. By improving the behavior of preschoolers, pharmacotherapy enables them to more optimally explore their worlds and take advantage of potentially important learning opportunities.

Proceed With Caution

Regardless of reported efficacy of stimulants in preschoolers, clinicians should still proceed with caution. Little is known about the effects of medicines on the neurochemistry of the brain, especially during periods of formative plasticity in the first 3 years of life. Does stimulant exposure in the first 3 years of life increase dopamine transporter density, thus exacerbating ADHD symptomatology in later years? Are homeostatic properties of the brain disrupted with early exposure to medicine? Given growing evidence, these outcomes are unlikely, but careful diagnosis and comprehensive management strategies are necessary to ensure the well-being of young children.

The guiding question of medication management in young children with severe ADHD is whether or not the benefit of treatment significantly improves the quality of life for the child and the family. A 2-year-old child with severe hyperactivity and chronic impulsive behavior who is shuttled from one foster family to another has a poor prognosis. That same child, treated, may have a chance of stability in the early years.

Although medical management is not a panacea for enabling preschoolers to more effectively control their behavior, it is nevertheless one piece of a comprehensive package that has the potential to improve the cognitive and social outcomes for young children.

IS THIS KIND OF DUBIOUS PRACTICE WHAT WE WANT IN THE U.K.?

NICE GUIDELINES SAY CATEGORICALLY NOT.

ADHD - A SOCIALLY CONSTRUCTED LABEL - PROFESSOR SAMI TIMIMI IN WIKIPEDIA

ADHD as a social construct.



DR PETER BREGGIN




PROFESSOR SAMI TIMIMI



Psychiatrists Peter Breggin and Sami Timimi oppose pathologizing the symptoms of ADHD. Sami Timimi, who is an NHS child and adolescent psychiatrist, explains ADHD as a social construct rather than an objective 'disorder'.[5] Timimi argues that western society creates stress on families which in turn suggests environmental causes for children expressing the symptoms of ADHD.[6] They also believe that parents who feel they have failed in their parenting responsibilities can use the ADHD label to absolve guilt and self-blame. A common argument against the medical model of ADHD asserts that while the traits that define ADHD exist and may be measurable, they lie within the spectrum of normal healthy human behaviour and are not dysfunctional. However, by definition, in order to diagnose with a mental disorder, symptoms must be interpreted as maladaptive. In America, the Diagnostic and Statistical Manual (DSM-IV) requires that "some impairment from the symptoms is present in two or more settings" and that "there must be clear evidence of significant impairment in social, school, or work functioning" for a diagnosis of ADHD to be made.[7]

In this view, in societies where passivity and order are highly valued, those on the active end of the active-passive spectrum may be seen as 'problems'. Medically defining their behaviour (by giving labels such as ADHD and ADD) serves the purpose of removing blame from those 'causing the problem'. Controversy over the social constructionist view comes from a number of studies that cite significant psychological and social differences between those diagnosed with the disorder, and those who are not. However, the specific reasons for these differences are not certain, and this does not suggest anything other than a difference in behavior. Studies have also shown neurological differences, but whether this signifies an effect rather than a cause is unknown. Such differences could also be attributed the drugs commonly prescribed to people with this disorder. Studies have also been able to differentiate ADHD from other psychiatric disorders in its symptoms, associated features, life course, and comorbidity.[8][9][10][11]

Gerald Coles, an educational psychologist and formerly an associate professor of clinical psychiatry at Robert Wood Johnson Medical School and the University of Rochester who has written extensively on literacy and learning disabilities, asserts that there are partisan agendas behind the educational policy-makers and that the scientific research that they use to support their arguments regarding the teaching of literacy are flawed. These include the idea that there are neurological explanations for learning disabilities. Gerald Coles argues that school failure must be viewed and treated in the context of both the learning environment and the child's individual abilities, behavior, family life, and social relationships. He then presents a new model of learning problems, in which family and school environments are the major determinants of academic success. In this "interactive" paradigm, the attitudes and methods of education are more important than inherent strengths or deficits of the individual child.[12]
[edit] Questioning the pathophysiological and genetic basis of ADHD
See also: Causes · Pathophysiology · ADHD as a biological illness

Some social constructionist theories of ADHD reject the dominant medical opinion that ADHD has a distinct pathophysiology and genetic components. The "symptoms" of ADHD also happen to be morally questionable attributes, this is why the symptoms as described as "inappropriate". Many social constructionists trenchantly question deterministic views of behaviour, such as those views sometimes put forth within behavioural/abnormal psychology and the biological sciences.

Currently, the pathophysiology of ADHD is unclear; although research has found evidence of differences in the brain between ADHD and non-ADHD patients.[13][14][15][16][17][18] Critics, such as Jonathan Leo and David Cohen who reject the characterization of ADHD as a disorder, contend that the controls for stimulant medication usage were inadequate in some lobar volumetric studies which makes it impossible to determine whether ADHD itself or psychotropic medication used to treat ADHD is responsible for decreased thickness observed[19] in certain brain regions.[20][21] They believe many neuroimaging studies are oversimplified in both popular and scientific discourse and given undue weight despite deficiencies in experimental methodology.[20]

From a biological/genetic point of view, ADHD is said to be highly heritable and twin studies suggest genetics are a factor in about 75% of ADHD cases,.[22] However, the genetic connection is questionable. Dr. Joseph Glenmullen states, "no claim of a gene for a psychiatric condition has stood the test of time, in spite of popular misinformation. Although many theories exist, there is no definitive biological, neurological, or genetic etiology for 'mental illness'."[23] His critics argue that ADHD is a heterogeneous disorder[22] caused by a complex interaction of genetic and environmental factors and thus cannot be modeled accurately using the single gene theory. Authors of a review of ADHD etiology have noted: "Although several genome-wide searches have identified chromosomal regions that are predicted to contain genes that contribute to ADHD susceptibility, to date no single gene with a major contribution to ADHD has been identified."[24]
[edit] Alternatives to medication

Social critics question if environmental changes should be the main line of treatment for those with a diagnosis of ADHD, instead of the medical model which predominantly uses medication and to a lesser extent, behavior modification. Critics believe schools and the health system force children to conform to a narrow, predefined standard of child development.[citation needed] These critics believe that these institutions are propagating the dangerous viewpoint that children with ADHD are maladaptive and disabled simply because they do not conform to a socially constructed norm.[who?] Some people including retired neurologist and CCHR medical expert Fred Baughman have suggested that this viewpoint is ultimately being pushed by the pharmaceutical industry in order to sell Anti-ADHD drugs.[25] Moreover, the argument against ADHD asserts that changing the child through medication regimes may cheat them of certain unique and positive personal characteristics that in turn may limit our collective future. For example, Ben Franklin was notorious for being a failure in the public education system yet became a highly regarded scientist, statesman, and public servant. Hartmann (2003) points out that had Ben Franklin been forced to fit in, the American Revolution may have never happened.[26] However, since Franklin's time, the educational system has become far more competitive and rigidly structured, and opportunities for professional success are highly dependent on the grades earned by a student. The personal characteristics which may be associated with ADHD are possibly less positive than they might have been before academic success became such a prominent part of social and professional advancement.
[edit] Sudbury model of democratic education schools' alternative

Some critics of the concept of learning disabilities and of special education take the position that every child has a different learning style and pace and that each child is unique, not only capable of learning but also capable of succeeding. These critics assert that applying the medical model of problem-solving to individual children who are pupils in the school system, and labeling these children as disabled, systematically prevents the improvement of the current educational system.

Describing current instructional methods as homogenization and lockstep standardization, alternative approaches are proposed, such as the Sudbury model of democratic education schools, an alternative approach in which children, by enjoying personal freedom thus encouraged to exercise personal responsibility for their actions, learn at their own pace rather than following a chronologically-based curriculum.[27][28][29][30][31] Proponents of unschooling have also claimed that children raised in this method do not suffer from learning disabilities.
[edit] Criticism

Critics of the social constructionist view contend that it presents no hard evidence in support of its own position. Proponents of this view disagree that criteria for falsifiability are lacking. One way, for example, is to show that there exists an objective characteristic possessed by virtually all diagnosed individuals which does not exist in any non-diagnosed individual. However, because diagnosis of psychiatric disorders is based on opinion, this would be difficult to prove. Also, whether this would demonstrate any actual abnormality as opposed to the labeling of certain behaviors is unknown. Current candidates for falsifiability include PET scans, genes, neuroanatomical differences, and life outcomes. However, none of these have been shown to be precise predictors of a diagnosis or lack thereof. Also, as previously stated, neurological differences do not indicate a cause, nor do genes indicate a direct impact.[citation needed] Such criteria are generally fulfilled by well-understood medical diseases.[citation needed]

Critics of this view also assert that it is not consistent with known findings. For instance, they claim that ADHD is as frequent in Japan and China as in the US[citation needed], yet in such societies (which supposedly favor child obedience and passivity) one would expect higher rates of ADHD if this theory were correct.[clarification needed] However, this is also disputed on the grounds that more aggressively obedient societies may suppress 'symptoms' of rebellion or 'ADHD'. The style in which individuals of these nationalities interact in their home countries, which is typically much more reserved and serious than in the United States, seems to suggest this[citation needed]. However, there is no solid proof of this assertion. Additionally, rates of medical diagnoses in China cannot be a reliable indicator of ADHD prevalence, especially for such non-life-threatening disorders as ADHD, due to the large peasant population in that country who cannot easily seek the services of a trained child psychologist. Timimi's view has been seriously criticized by Russell Barkley and numerous experts in Child and Family Psychology Review (2005). In any case, it has been shown that Chinese and Indonesian clinicians give significantly higher scores for hyperactive-disruptive behaviors than did their Japanese and American colleagues when evaluating the same group of children.[32] Significant differences in the prevalence of ADHD across different countries have been reported, however.[33] Timimi himself cites a range of prevalence that goes from 0.5% to 26% as support for his theory.[citation needed]

 REFERENCES.

1. Parens E, Johnston J (2009). "Facts, values, and Attention-Deficit Hyperactivity Disorder (ADHD): an update on the controversies". Child Adolesc Psychiatry Ment Health 3 (1): 1. doi:10.1186/1753-2000-3-1. PMC 2637252. PMID 19152690.
  2.Singh I (December 2008). "Beyond polemics: science and ethics of ADHD". Nat. Rev. Neurosci. 9 (12): 957–64. doi:10.1038/nrn2514. PMID 19020513.
  3.Chriss, James J. (2007). Social control: an introduction. Cambridge, UK: Polity. p. 230. ISBN 0-7456-3858-9.
  4.Szasz, Thomas Stephen (2001). Pharmacracy: medicine and politics in America. New York: Praeger. p. 212. ISBN 0-275-97196-1.
  http://bjp.rcpsych.org/cgi/content/full/184/1/8 (Timimi, 2002
5.Timimi, S. & Begum, M. (2006). Critical Voices in Child and Adolescent Mental Health. London: Free Association Books.
  http://www.psychiatryonline.com/content.aspx?aID=7721
  6.Sami Timimi and Eric Taylor (2004) In Debate: ADHD is best understood as a cultural construct. The British Journal of Psychiatry 184: 8-9.
  7.Taylor, E., Chadwick, O., Heptinstall, E., et al. (1996) Hyperactivity and conduct problems as risk factors for adolescent development. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 1213–1226.
  8.Taylor, E., Sandberg, S., Thorley, G., et al. (1991) The Epidemiology of Childhood Hyperactivity. Maudsley Monograph No. 33. Oxford: Oxford University Press.
  9.Meltzer, H., Gatward, R., Goodman, R., et al. (2000) Mental Health of Children and Adolescents in Great Britain. London: Stationery Office.
  10.Gerald Coles (1987). The Learning Mystique: A Critical Look at "Learning Disabilities". Accessed November 25, 2008.
  Brain Matures a Few Years Late in ADHD, But Follows Normal Pattern NIMH Press Release, November 12, 2007
  11.Lou HC, Andresen J, Steinberg B, McLaughlin T, Friberg L. "The striatum in a putative cerebral network activated by verbal awareness in normals and in ADHD children." Eur J Neurol. 1998 Jan;5(1):67–74. PMID 10210814
12.Gene Predicts Better Outcome as Cortex Normalizes in Teens with ADHD NIMH Press Release, August 6, 2007
 13.Dougherty DD, Bonab AA, Spencer TJ, Rauch SL, Madras BK, Fischman AJ (1999). "Dopamine transporter density in patients with attention deficit hyperactivity disorder". Lancet 354 (9196): 2132–-33. doi:10.1016/S0140-6736(99)04030-1. PMID 10609822.
  14.Dresel SH, Kung MP, Plössl K, Meegalla SK, Kung HF (1998). "Pharmacological effects of dopaminergic drugs on in vivo binding of [99mTc]TRODAT-1 to the central dopamine transporters in rats". European journal of nuclear medicine 25 (1): 31–9. PMID 9396872.
  15.Coccaro EF, Hirsch SL, Stein MA (2007). "Plasma homovanillic acid correlates inversely with history of learning problems in healthy volunteer and personality disordered subjects". Psychiatry research 149 (1–3): 297–302. doi:10.1016/j.psychres.2006.05.009. PMID 17113158.
  16.Philip Shaw, MD; Jason Lerch, PhD; Deanna Greenstein, PhD; Wendy Sharp, MSW; Liv Clasen, PhD; Alan Evans, PhD; Jay Giedd, MD; F. Xavier Castellanos, MD; Judith Rapoport, MD (2006). "Longitudinal Mapping of Cortical Thickness and Clinical Outcome in Children and Adolescents With Attention-Deficit/Hyperactivity Disorder". Arch Gen Psychiatry 5 (63): 540–549. doi:10.1001/archpsyc.63.5.540. PMID 16651511.
  17.David Cohen; Jonathan Leo (2004). "An Update on ADHD Neuroimaging Research" (PDF). The Journal of Mind and Behavior (The Institute of Mind and Behavior, Inc) 25 (2): 161–166. ISSN 0271–0137.
  18.David Cohen; Jonathan Leo (2003). "Broken brains or flawed studies? A critical review of ADHD neuroimaging studies". The Journal of Mind and Behavior 24: 29–56.
  19.Barkley, Russel A.. "Attention-Deficit/Hyperactivity Disorder: Nature, Course, Outcomes, and Comorbidity". Retrieved 2006-06-26.
  20.Glenmullin, Joseph (2000). Prozac Backlash. New York: Simon & Schuster, 192-198
  21.M. T. Acosta, M. Arcos-Burgos, M. Muenke (2004). "Attention deficit/hyperactivity disorder (ADHD): Complex phenotype, simple genotype?". Genetics in Medicine 6 (1): 1–15. doi:10.1097/01.GIM.0000110413.07490.0B. PMID 14726804.
adhdfraud.org
 22.Hartmann, T.(2003). The Edison Gene: ADHD and the Gift of the Hunter Child. VT: Park Street Press.
  23.Greenberg, D. (1992), Education in America, A View from Sudbury Valley, "Special Education" -- A noble Cause Sacrificed to Standardization.
  24.Greenberg, D. (1992), Education in America, A View from Sudbury Valley, "Special Education" -- A Noble Cause Run Amok.
  25.Greenberg, D. (1987), Free at Last, The Sudbury Valley School, Chapter 1, And 'Rithmetic.
26. Greenberg, D. (1987), Free at Last, The Sudbury Valley School, Chapter 5, The Other 'R's'.
 27. Greenberg, D. (1987), Free at Last, The Sudbury Valley School, Chapter 19, Learning.
  28. E. M. Mann, Y. Ikeda, C. W. Mueller, A. Takahashi, K. T. Tao, E. Humris, B. L. Li, D. Chin (1992). "Cross-cultural differences in rating hyperactive-disruptive behaviors in children". American Journal of Psychiatry 149 (11): 1539–1542. PMID 1415822.

HANSARD - Written questions and answers on Ritalin Prescription Rates - Pat Mc Mullan,MP,Wolverhampton SE

Pat McFadden MP: To ask the Secretary of State for Health 

(1) if he will estimate the number of children who have been prescribed Ritalin or a similar drug;

(2) if he will estimate the number of children under the age of six who have been prescribed Ritalin or a similar drug; and if he will assess trends in the number of such prescriptions in the last five years;

(3) if he will estimate the number of children under the age of six in Wolverhampton who have been prescribed Ritalin or a similar drug;

(4) what guidance (a) his Department and (b) the National Institute for Health and Clinical Excellence issues to practitioners on the prescription of Ritalin and similar drugs to young children.

Anne Milton: I refer the right hon. Member to the answer I gave the right hon. Member for Birkenhead (Mr Field) on 4 April 2011, Official Report, column 684W.

The Information Centre Prescribing Team has advised that this information is not available for children's prescriptions. They have however provided information on the numbers of all Ritalin prescriptions dispensed in the community as follows:

Ritalin is a branded version of the drug Methylphenidate Hydrochloride. The following table shows the total number of items dispensed for Methylphenidate Hydrochloride overall (including Ritalin) and for Ritalin separately for individuals of all ages.

Methylphenidate Hydrochloride prescriptions dispensed in the community in England


Thousand


  

Prescription items


  

Methylphenidate Hydrochloride

  

Of which : Ritalin

1997
  

92.1
  

92.1

1998
  

126.6
  

126.6

1999
  

158.0
  

157.9

2000
  

186.2
  

181.3

2001
  

208.5
  

180.6

2002
  

254.0
  

161.8

2003
  

314.5
  

124.5

2004
  

359.1
  

67.8

2005
  

389.2
  

30.7

2006
  

456.9
  

26.5

2007
  

535.3
  

25.5

2008
  

573.4
  

22.8

2009
  

610.2
  

20.2

Notes:

EVIDENCE ON PRESCRIPTION DRUG ABUSE IN U.S.- FROM NATIONAL INSTITUTE ON DRUG ABUSE'S DIRECTOR DR NORA VOLKOW TO SENATE SUBCOMMITTEE ON CRIME AND DRUG ABUSE IN 2008 + FACTSHEET FROM NIDA ON METHYLPHENIDATE

Nora D. Volkow, M.D.
Director of NIDA
U.S. Department of Health and Human Services


WATCH YOUTUBE VIDEO INTERVIEW ON LINK BELOW OR BY CLICKING ON TITLE THEN READ TRANSCRIPT OF EVIDENCE GIVEN TO SENATE SUB COMMITTEE.

http://www.youtube.com/watch?v=imCJSY06M40 

on
Scientific Research on Prescription Drug Abuse
before
Judiciary Committee
Subcommittee on Crime and Drugs
U.S. Senate

Mr. Chairman, Members of the Subcommittee, and Members of the Caucus:

Thank you for inviting the National Institute on Drug Abuse (NIDA), a component of the National Institutes of Health (NIH), an agency of the Department of Health and Human Services (HHS), to participate in this important hearing and contribute information about the growing problem of prescription drug abuse in this country. This problem is particularly complex because the benefits and the risks of prescription drugs are so closely intertwined. Thus, it is critical that we learn how to strike the right balance between providing maximum relief from suffering and minimizing associated risks and adverse effects. We must be deeply concerned by the fact that, according to the Monitoring the Future (MTF) study supported by NIDA, 7 of the top 11 most commonly abused drugs by high school seniors are either prescribed or purchased over-the-counter (see figure), but this challenge must also recognize the fundamental and unassailable role played by these medications in healing and reducing human suffering when properly used. Therefore, how we address the problem of abuse of drugs that have legitimate medical use must necessarily differ from how we address illicit drug abuse.

Several factors have recently contributed to the severity of prescription drug abuse, including drastic increases in the number of prescriptions written, greater social acceptance of using medications, and aggressive marketing by pharmaceutical companies. These factors together have helped create the broad “environmental availability” of prescription drugs. To illustrate, the total number of stimulant prescriptions in the U.S. has soared from around 5 million in 1991 to nearly 35 million in 2007. Prescriptions for opiates (hydrocodone and oxycodone products) have escalated from around 40 million in 1991 to nearly 180 million in 2007 (see figure), with the U.S. their biggest consumer. The U.S. is supplied 99 percent of the world total for hydrocodone (e.g., Vicodin) and 71 percent of oxycodone (e.g., OxyContin).

This greater availability of prescription drugs has been accompanied by increases in their abuse. 
 To clarify our terminology here, when we say “prescription drug abuse” or “nonmedical use,” this includes use of approved prescription medications without a prescription, use for purposes other than prescribed, or use simply for the experience or feeling the drug can cause. Unlike illicit drug use, which shows a continuing downward trend, prescription drug abuse, particularly of opioid pain medications, has seen a continual rise through the 1990s and has remained stubbornly steady among persons 12 or older during recent years.[1] Because prescription drugs act directly or indirectly on the same brain systems affected by illicit drugs, their abuse carries substantial abuse and addiction liabilities. They are most dangerous when taken to get high via methods that increase their addictive potential (e.g., crushing the pills, then snorting or injecting their contents, or combining them with alcohol or illicit drugs). Some people also take prescription drugs for their intended purpose, though not as prescribed, thus heightening the risk of dangerous adverse reactions; and still others may become addicted even when they take them as prescribed. Given that more than 30 million people suffer from chronic pain in this country, even if a fraction of this group takes prescription drugs for their pain and becomes addicted, it could affect a large number of people.

I am pleased to have the opportunity today to share with you what we know about this complex multi-faceted problem.

Which medications are being abused, and what do they do to the brain and body?

The psychotropic prescription drugs[2] that present abuse liability (i.e., have potential for abuse relative to their pharmacological and behavioral effects) fall into three broad categories: opioids (analgesics), stimulants, and central nervous system (CNS) depressants (anxiety and sleep medications). How they work is described briefly below:

    Opioids, mostly prescribed to treat moderate to severe pain, include drugs such as OxyContin and Vicodin.  Opioids act on the brain and body by attaching to specific cell surface proteins called opioid receptors, which are found in the brain, spinal cord, and gastrointestinal tract. When these drugs attach to certain opioid receptors, they can block the perception of pain. These drugs also can induce euphoria by indirectly boosting dopamine levels in the brain regions that influence our perceptions of pleasure. This feeling is often intensified by abusers who snort or inject the drugs, amplifying their euphorigenic effects and increasing the risk for serious medical consequences, such as respiratory arrest, coma, and addiction. Combining opioids with alcohol can exacerbate these consequences.

    Stimulants, prescribed to treat attention-deficit hyperactivity disorder (ADHD) and narcolepsy, include drugs such as Ritalin, Adderall, and Concerta. These prescription medications stimulate the central nervous system, with effects similar to but more potent than caffeine. When taken orally, as prescribed, these stimulants elicit a gradual and sustained increase in the neurotransmitter (brain chemical) dopamine, which produces the expected therapeutic effects seen in many patients. In people with ADHD, stimulant medications generally have a calming and "focusing" effect, particularly in children. However, because these medications affect the dopamine system in the brain (the reward pathway), they are also similar to drugs of abuse. For example, Ritalin, or methylphenidate, has much in common with cocaine––the two drugs bind to similar sites in the brain and both increase dopamine through the same molecular targets (see figure). When administered intravenously, both drugs cause a rapid and large increase in dopamine, which a person experiences as a rush or high. For those who abuse stimulants, the range of adverse health consequences includes risk of dangerously high body temperature, seizures, and cardiovascular complications.

    CNS depressants, typically prescribed for the treatment of anxiety, panic, sleep disorders, acute stress reactions, and muscle spasms, includes drugs such as Valium, Librium, and Xanax. Most CNS depressants act on the brain by affecting the neurotransmitter gammaaminobutyric acid (GABA). GABA works by decreasing brain activity. Although the different classes of CNS depressants work in unique ways, it is through their ability to increase GABA activity that they produce a drowsy or calming effect that is beneficial to those suffering from anxiety or sleep disorders. These drugs are also particularly dangerous when mixed with other medications or alcohol; overdose can cause breathing problems and lead to death. Although the newer sleep medications—such as Ambien, Lunesta, and Sonata––appear to have reduced dependence and abuse liabilities, they still react with some of the same receptors in the brain, so they may share some of the risks.

Over the counter medications, such as certain cough suppressants containing dextromethorphan (DXM), are also abused for their psychoactive effects, producing hallucinations and dissociative (“out-of-body”) sensations. However, overdose of DXM can also produce confusion, disorientation, motor impairment, blurred vision, nausea, rapid or irregular heartbeat, high blood pressure, and loss of consciousness.

What is the scope of the prescription drug problem in this country?

Several indicators show that prescription drug abuse is a significant problem in the United States. According to the National Survey on Drug Use and Health (NSDUH), conducted by HHS’s Substance Abuse and Mental Health Services Administration (SAMHSA), in 2006 approximately 7 million persons 12 and older took a psychotherapeutic drug for non-medical purposes in the 30 days before the survey. Most reported abusing opiate pain relievers in particular. In fact, 2.2 million persons aged 12 and over initiated abuse of pain relievers in the past year (see figure). Young adults (ages 18-25) by far showed the greatest use overall and the largest increases in past month, past year, and lifetime use between 2002 and 2006, compared to all other age groups (NSDUH, 2007). Still, even by the time they graduate from high school, roughly a quarter of 12th graders report having abused a prescription drug (MTF, 2007). Other significant indicators of the prescription drug problem include the following:

    In 2006, more than half a million adolescents aged 12-17 used stimulants nonmedically in the past year (NSDUH, 2007).

    Although abuse of sedatives decreased among high school seniors between 2005 and 2007, it is still near peak levels, at over 6 percent among this group (MTF, 2007).

    Nearly 6 percent of 12th graders reported abusing cough medicine to get high in 2007 (MTF, 2007).

    Data on drug-related emergency department visits that involved prescription opioids show a 153 percent increase from 1995–2002, from 42,857 to 108,320 (SAMHSA’s Drug Abuse Warning Network, 2004).

    Treatment admissions for opiates other than heroin surged from 16,121 in 1995 to 67,887 in 2005, a 321 percent increase (SAMHSA’s Treatment Episode Data Set, 1995–2005).

    Prescribed pain medications are driving the upward trend in drug poisoning mortality. The number of deaths involving prescription opioid analgesics increased 160 percent in just 5 years from 1999 to 2004. By 2004, opioid painkiller abuse deaths outnumbered total deaths involving heroin and cocaine (HHS’s Centers for Disease Control and Prevention, 2006).

What factors are driving abuse of prescription drugs?

The far-ranging scope of prescription drug abuse in this country stems not only from the greater prescribing of medications, but also from misperceptions of their safety. For example, many students, and even some parents, see nothing wrong in the abuse of stimulants to improve cognitive function and academic performance. In fact, being in college may even be a risk factor for greater use of amphetamines or Ritalin nonmedically, with reports of students taking pills before tests and of those with prescribed medications being approached to divert them to others. Pain relievers show a similar link with regard to access. Evidence suggests that parents sometimes provide their children with prescription medications not prescribed by a physician for the child to relieve their discomfort.[3] According to the 2006 NSDUH, 55.7 percent of those 12 and older who misused pain relievers said they received their medications from a friend or family member, the vast majority of whom had gotten the drugs from just one doctor. Only 3.9 percent cited obtaining these drugs from a drug dealer or stranger, and only 0.1 percent cited an internet purchase. Notably, the leading reason for the abuse is to relieve pain, although other top motives include intent to get high and experimentation.

Similar motivations characterize younger groups, with high school students reporting that they primarily abuse prescription drugs for the medications’ intended purpose, albeit without a prescription. Using these medications without a prescription or in ways other than prescribed poses multiple risks, including dangerous interactions with other medications, accidental poisoning, and risk of addiction.

Nonmedical use among children and adolescents is particularly troublesome, given that adolescence is the period of greatest risk not only for drug experimentation but also for developing addiction. At this stage, the brain is still developing and exposure to drugs could interfere with these carefully orchestrated developmental changes. Today we know that the last part of the brain to fully mature is the prefrontal cortex, a region that governs judgment and decision-making functions. This may help explain why teens are prone to risk-taking and to experimentation with alcohol and other drugs.

Research also shows that adolescents who abuse prescription drugs are twice as likely to have engaged in delinquent behavior and nearly three times as likely to have experienced an episode of major depression compared to teens who did not abuse prescription medications over the past year. Finally, several studies link the illicit use of prescription drugs with increased rates of cigarette smoking, heavy drinking, and marijuana and other illicit drug use in adolescents and young adults in the U.S.

Older adults represent another area for particular concern. Although this group currently comprises just 13 percent of the U.S. population, they receive approximately one-third of all medications prescribed in the Nation. In a culture in which medications are considered a “quick fix” for whatever ails you, combined with the greater rates of lifetime drug abuse among the “baby boom” generation as compared to those in the current older generation relative to its size, it is possible that the number of persons aged 50 or older abusing prescription drugs could increase 190 percent over the next two decades, from 911,000 in 2001 to almost 2.7 million in 2020.[4] Because older adults also experience higher rates of other illness as well as normal changes in drug metabolism, it makes sense that even moderate abuse or unintentional misuse of prescription drugs by elderly persons could lead to more severe health consequences. Therefore, physicians need to be aware of the possibility of abuse and to discuss the health implications with their patients.

What is NIDA doing about it?

Recognizing the dangerous trend of prescription drug abuse as well as the need to promote additional research on the subject and to inform the public, physicians, pharmacists, and others, NIDA first launched its prescription drug abuse public health initiative in 2001. Through NIDA’s support of surveillance instruments, including our Community Epidemiology Work Group and the Monitoring the Future survey, we continuously monitor trends in all forms of drug abuse, including the abuse of prescribed medications. In addition, NIDA and ONDCP are co-sponsoring an initiative on designing appropriate questions for screening and brief interventions for prescription drug abuse. Identifying trends as soon as they begin to surface in the population helps NIDA continue to lead the effort to surmount increasing abuse through a multi-pronged strategy intended to complement and expand our already robust portfolio of basic, preclinical, and clinical research and educational and outreach initiatives targeting the prescription drug phenomenon.

Targeted research initiatives. Although opioid medications effectively treat pain, their addiction risk presents a dilemma for healthcare providers who seek to relieve suffering while preventing drug abuse and addiction. Little is yet known about the risk for addiction among those being treated for chronic pain, or how basic pain mechanisms interact with prescription opioids to influence addiction potential. Therefore, NIDA recently launched a research initiative on "Prescription Opioid Use and Abuse in the Treatment of Pain," which encourages a multidisciplinary approach using both human and animal studies from across the sciences to examine factors (including pain itself) that predispose or protect against opioid abuse and addiction. Funded grants cover clinical neurobiology, genetics, molecular biology, prevention, treatment, and services research. This type of information will help develop screening and diagnostic tools that physicians can use to assess the potential for prescription drug abuse in their patients. Because opioid medications are prescribed for all ages and populations, NIDA is also encouraging research that assesses the effects of prescription opioid abuse by pregnant women, children, and adolescents, and how it might increase the lifetime risk of substance abuse and addiction.

Another important initiative pertains to the development of new approaches to treat pain, which reduce the potential for abuse. For example, compounds are being developed that act on a combination of two distinct opioid receptors (mu and delta), preclinical studies showing them to induce strong analgesia without producing tolerance or dependence. Researchers are also getting closer to developing a new generation of non–opioid-based medications for pain that would circumvent the brain reward pathways, thereby greatly reducing abuse potential. Included are compounds that work through a cannabinoid receptor subtype located primarily in the peripheral nervous system. NIDA is also exploring the use of “neurofeedback,” where patients learn to regulate neural activity in specific brain regions by getting pictorial representations from the activity in those areas fed back to them in real-time. This technique has shown promising results for altering the perception of pain in healthy adults and chronic pain patients and could even evolve into a powerful psychotherapeutic intervention capable of rescuing the circuits and behaviors impaired by addiction.

NIDA is also leading efforts in the treatment of addiction to prescription pain relievers. Our Clinical Trials Network is sponsoring the first large-scale, multi-site national study on the treatment of addiction to prescription pain medication, testing the effectiveness of buprenorphine/naloxone, a medication used in the treatment of heroin addiction, along with different models of drug counseling.

Education and Outreach. Education is a critical component of any effort to curb the abuse of prescription medications and must target every segment of society. For example, NIDA is advancing addiction awareness, prevention, and treatment in primary care practices, including the diagnosis of prescription drug abuse, having established four Centers of Excellence for Physician Information. Intended to serve as national models, the Centers will target physicians-in-training, including medical students and resident physicians in primary care specialties (e.g., internal medicine, family practice, and pediatrics). In a more general vein, we will also continue our close collaborations with the Office of National Drug Control Policy, SAMHSA, and other Federal agencies, as well as professional associations with a strong interest in preserving public health. NIDA recently sponsored a 2-day meeting in conjunction with the American Medical Association and the NIH Pain Consortium (an NIH initiative established to enhance pain research and promote collaboration among researchers across the many NIH Institutes and Centers that have programs and activities addressing pain), where more than 500 medical professionals, scientific researchers, and interested members of the public had a chance to dialogue about the problems of prescription opioid abuse and to learn about new areas of research.

Prevention strategies. Because prescription drugs are safe and effective when used properly and are broadly marketed to the public, the notion that they are also harmful and addictive when abused can be a difficult one to convey. Thus, we need focused research to discover targeted communication strategies that effectively address this problem. Reaching this goal may be significantly more complex and nuanced than developing and deploying effective programs for the prevention of abuse of illicit drugs, but good prevention messages based on scientific evidence will be difficult to ignore.

Conclusion

In conclusion, it is hardly surprising that the availability of more, new, better, and safer psychotherapeutics has been followed by a huge upswing in the prevalence of their non-medical use and abuse by varied populations. We should be seriously concerned: for although prescription drugs can be powerful allies, they also pose serious health risks related to their abuse, which can lead to addiction and to death. It will be a question of balance, difficult to achieve, so that people suffering from chronic pain, ADHD, or anxiety can get the relief they need while minimizing the potential for abuse.

Consistent with one of NIDA's most important goals, our response has been framed by our commitment to translate what we know from research to help the public better understand drug abuse and addiction, and to develop more effective strategies for their prevention and treatment.

Thank you for the opportunity to provide this information to you.



[1] The NSDUH Report: Patterns and Trends in Nonmedical Prescription Pain Reliever Use: 2002 to 2005, Substance Abuse and Mental Health Services Administration, Department of Health and Human Services, 2007.

[2] For purposes of this testimony, the focus will be only on psychotherapeutic drugs, so even though NIDA’s prescription drug portfolio includes work on other prescribed drug categories, such as anabolic steroids, these will be excluded from this discussion.

[3] Boyd et al. Medical and nonmedical use of prescription pain medication by youth in a Detroit-area public school district. Drug and Alchol Dependence 81:37-45, 2006.

[4] Colliver JD, Compton WM, Grroerer JC, Condon, T. Projecting drug use among aging baby boomers in 2020.

Ann Epidemiol. 2006 Apr;16(4):257-65

Last revised: April 19, 2011
  

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NIDA InfoFacts: Stimulant ADHD Medications - Methylphenidate and Amphetamines

Stimulant medications (e.g., methylphenidate and amphetamines) are often prescribed to treat individuals diagnosed with attention-deficit hyperactivity disorder (ADHD). ADHD is characterized by a persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequently displayed and more severe than is typically observed in individuals at a comparable level of development. This pattern of behavior usually becomes evident in the preschool or early elementary years, and the median age of onset of ADHD symptoms is 7 years. For many individuals, ADHD symptoms improve during adolescence or as age increases, but the disorder can persist into adulthood. In the United States, ADHD is diagnosed in an estimated 8 percent of children ages 4–17 and in 2.9–4.4 percent of adults.1,2,3
How Do Prescription Stimulants Affect the Brain?

All stimulants work by increasing dopamine levels in the brain—dopamine is a brain chemical (or neurotransmitter) associated with pleasure, movement, and attention. The therapeutic effect of stimulants is achieved by slow and steady increases of dopamine, which are similar to the natural production of the chemical by the brain. The doses prescribed by physicians start low and increase gradually until a therapeutic effect is reached. However, when taken in doses and routes other than those prescribed, stimulants can increase brain dopamine in a rapid and highly amplified manner—as do most other drugs of abuse—disrupting normal communication between brain cells, producing euphoria, and increasing the risk of addiction.
What Is the Role of Stimulants in the Treatment of ADHD?

Treatment of ADHD with stimulants, often in conjunction with psychotherapy, helps to improve the symptoms of ADHD, as well as the self-esteem, cognition, and social and family interactions of the patient. The most commonly prescribed medications include amphetamines (e.g., Adderall®, a mix of amphetamine salts) and methylphenidate (e.g., Ritalin and Concerta—a formulation that releases medication in the body over a period of time). These medications have a paradoxically calming and “focusing” effect on individuals with ADHD. Researchers speculate that because methylphenidate amplifies the release of dopamine, it can improve attention and focus in individuals who have dopamine signals that are weak.4

One of the most controversial issues in child psychiatry is whether the use of stimulant medications to treat ADHD increases the risk of substance abuse in adulthood. Research thus far suggests that individuals with ADHD do not become addicted to their stimulant medications when taken in the form and dosage prescribed by their doctors. Furthermore, several studies report that stimulant therapy in childhood does not increase the risk for subsequent drug and alcohol abuse disorders later in life.5,6,7 More research is needed, however, particularly in adolescents treated with stimulant medications.
Why and How Are Prescription Stimulants Abused?

Stimulants have been abused for both “performance enhancement” and recreational purposes (i.e., to get high). For the former, they suppress appetite (to facilitate weight loss), increase wakefulness, and increase focus and attention. The euphoric effects of stimulants usually occur when they are crushed and then snorted or injected. Some abusers dissolve the tablets in water and inject the mixture. Complications from this method of use can arise because insoluble fillers in the tablets can block small blood vessels.
What Adverse Effects Does Prescription Stimulant Abuse Have on Health?

Stimulants can increase blood pressure, heart rate, body temperature, and decrease sleep and appetite, which can lead to malnutrition and its consequences. Repeated use of stimulants can lead to feelings of hostility and paranoia. At high doses, they can lead to serious cardiovascular complications, including stroke.

Addiction to stimulants is also a very real consideration for anyone taking them without medical supervision. This most likely occurs because stimulants, when taken in doses and routes other than those prescribed by a doctor, can induce a rapid rise in dopamine in the brain. Furthermore, if stimulants are used chronically, withdrawal symptoms—including fatigue, depression, and disturbed sleep patterns—can emerge when the drugs are discontinued.
How Widespread Is Prescription Stimulant Abuse?

Monitoring the Future Survey*
Each year, the Monitoring the Future (MTF) survey assesses the extent of drug use among 8th-, 10th-, and 12th-graders nationwide. For amphetamines and methylphenidate, the survey measures only past-year use, which refers to use at least once during the year preceding an individual’s response to the survey. Use outside of medical supervision was first measured in the study in 2001; nonmedical use of stimulants has been falling since then, with total declines between 25 percent and 42 percent at each grade level surveyed. MTF data for 2008 indicate past-year nonmedical use of Ritalin by 1.6 percent of 8th-graders, 2.9 percent of 10th-graders, and 3.4 percent of 12th-graders.

Since its peak in the mid-1990s, annual prevalence of amphetamine use fell by one-half among 8th-graders to 4.5 percent and by nearly one-half among 10th-graders to 6.4 percent in 2008. Amphetamine use peaked somewhat later among 12th-graders and has fallen by more than one-third to 6.8 percent by 2008. Although general nonmedical use of prescription stimulants is declining in this group, when asked, “What amphetamines have you taken during the last year without a doctor’s orders?” 2.8 percent of all 12th-graders surveyed in 2007 reported they had used Adderall. Amphetamines rank third among 12th-graders for past-year illicit drug use.
Other Information Sources

For more information on treating ADHD, visit the Web site for the National Institute of Mental Health, National Institutes of Health, at www.nimh.nih.gov.
For street terms searchable by drug name, street term, cost and quantities, drug trade, and drug use, visit www.whitehousedrugpolicy.gov/.

WISE UP JOURNAL - BEHAVIOUR DRUGS GIVEN TO FOUR YEAR OLDS PROMPTS CALL FOR INQUIRY.

Behaviour drugs given to four-year-olds prompt calls for inquiry

Guardian

18.03.2011
By Rowenna Davis

ets.ADHD medication given in breach of NHS guidelines as professor says parents putting pressure on GPs

Children as young as four are being given Ritalin-style medication for behavioural problems in breach of NHS guidelines, the Guardian has discovered, prompting the leading psychological society to call for a national review.

Family-based therapy is recommended for treating children with ADHD (attention deficit hyperactivity disorder), with prescription drugs used only for children over six years old and as a last resort.

The figures, based on data from 479 GPs, show prescription rates were highest for children aged six to 12, doubling to just over eight per 1,000 in the five years up to 2008. Children aged 13 to 17 had the second highest rate at six per 1,000, while those aged 25 and over had less than one per 1,000.

Concern is greatest over children under six who should not be receiving drugs at all, says the National Institute for Health and Clinical Excellence (Nice).

There are no reliable figures for how many children under six have been given Ritalin. But Professor Tim Kendall, joint director of the National Collaborating Centre for Mental Health, who chaired the Nice guideline committee, confirmed that he had heard reliable reports of children in nursery and pre-school being prescribed medication unnecessarily, and that it was often parents who were putting pressure on GPs.

He said: “There are two reasons why parents go shopping for a diagnosis. The first is to improve their child’s performance at school, and the second is to get access to benefits. There are always GPs that will do it, but it’s wrong to give a child a diagnosis without also consulting schools and teachers.”

In one case seen by the Guardian, a five-year-old from the West Midlands was found to be receiving a double dose of methylphenidate, commonly known by the brand name Ritalin, the drug used to treat ADHD, despite his school insisting that he is “among the best-behaved children in his class”.

In notes seen by the leading educational psychologist in the case, the boy’s headteacher reports that the school does not believe he has ADHD, but that the medication is being prescribed “to help mum at home”.

In another case in the West Midlands a five-year-old was put on the drugs for three years at the request of his parents without any consultation with teachers or psychologists.

Speaking on behalf of the British Psychological Society, Peter Kinderman, chair of the division of clinical psychology, said he supported calls for a review, saying he would be concerned if children were being prescribed medication as a quick fix.

He added that mental health services were already “grossly under-resourced” and that cuts were likely to put services to children at risk.

Kinderman expressed particular worries about the cases uncovered by the Guardian. “Many psychologists are very concerned at the use of psychiatric and medical diagnoses in cases such as mild social anxiety or shyness, not only because of doubts about the validity of many of the diagnostic approaches, but because of the possible adverse effects.”

But Dinah Jayson, consultant child and adolescent psychiatrist at Trafford general hospital and a spokesperson for the Royal College of Psychiatrists, insisted that in some cases it could be “cruel” not to treat children of any age if all other options had been exhausted.

She said: “With every child there is a risk of doing something but there is also a risk of doing nothing. We know early [medical] intervention can help children who would otherwise be losing out.”

“GPs and psychiatrists are much more aware of mental illness, and the drugs are so effective and have such a big effect that it’s tipped the balance. They [drugs] can make a real difference not just to the child but to households and classrooms where children may be causing real disruption.”

According to Nice guidelines, between 1% and 9% of young people in the UK now have some form of ADHD, depending on the criteria used. NHS figures show a rise in all methylphenidate prescriptions across all age groups by almost 60% in five years, rising from 389,200 in 2005 to 610,200 in 2009.

Side-effects include sleeplessness, appetite loss and reduced growth rates. Wong, who says the long-term effects are inconclusive, recently received a €3m (£2.6m) grant from the European commission to investigate side-effects further.

Professor Paul Cooper, a psychologist and professor of education based at Leicester University, who has completed qualitative research with adolescents on psychostimulant medication, expressed concerns about the possible effects of the drugs on personality development.

“Some young people say that it affects their personality but accept it because it gets mum and dad off their case or stops them getting into trouble,” he said. “They don’t like it, but take it for the benefit of other people.”

Medical experts in the West Midlands say over-prescription continues to be a problem. “This whole area needs public scrutiny – there has to be some kind of review,” said the educational psychologist who oversaw the cases but did not want to be named. “Handing out strong psychotropic drugs to children should be a last resort, but they’re being handed out like sweets.”

BIOSOCIETIES - JUNE 2007- HOW A SOCIETY CONSTRUCTS THE NORMS OF MENTAL ILLNESS AND MENTAL HEALTH - " IL BAMABINO E LE DROGHE "

I Bambini e le Droghe’: The Right to Ritalin vs the Right to Childhood in Italy
Giovanni Frazzettoa1 c1, Sinéad Keenana1 and Ilina Singha1
a1 BIOS, London School of Economics and Political Science, Houghton Street, London WC2A 2AE UK

DRUG AN INFANT OR STROKE A DOG TO STAY CALM?

Abstract

Despite the widespread consumption of stimulant drugs such as Ritalin (methylphenidate) for the treatment of children with attention deficit/hyperactivity disorder (ADHD), understanding of the differing national realities of the ADHD/methylphenidate phenomenon is especially impoverished. In this article, we give an introductory description of the scientific-historical, cultural and ideological factors that have shaped the diagnosis of ADHD and its treatment in Italy. Qualitative empirical analysis of the national debate on the use of methylphenidate and of parents’ experiences with the drug reveals that, in the Italian context, the evolution of the ADHD/Ritalin phenomenon has been largely shaped by dynamics within the country’s psychiatric practices and health system, as well as by attitudes towards mental illness. We suggest that in Italy, the current dynamics in the regulation of methylphenidate inscribe ADHD diagnosis and stimulant drug treatment as moral choices. On both the political and the familial level, these choices are grounded in sometimes opposing conceptions of vital civil rights and national ideals: the ‘right to medication’, the ‘right to mental health care’ and the ‘right to childhood’. Our study illustrates that close analysis of specific cultural contexts can be useful in understanding how attitudes towards mental disorders and the use of psychotropic drugs can be shaped by the social practices and medical habits of a country.