ADHD - how many of our children need drugs?

Last week, we asked a local paediatrician to talk to our practice about ADHD. Dr Crippen is deeply uneasy about this “disease”. Indeed, he is not convinced it is a “disease” at all. He has written several times about the way that ADHD is promulgated by the drug companies, and how uneasy he is about putting children on amphetamine-related drugs. "Speed." "Whiz." Ask your parents about “purple hearts.” - and we are not talking of medals.

This paediatrician was particularly enthusiastic about papers written by Dr Geoff Kewley. Geoff was a consultant paediatrician. He has written a personal paper in the BMJ about ADHD. He was so concerned about the lack of diagnosis and facilities for children with ADHD that he left the NHS to establish an independent private clinic, The Learning Assessment and Neurocare Centre in Horsham. This clinic is highly regarded by the families who attend it.

“The Centre was established by Dr Geoff Kewley, Consultant Paediatrician, in 1993 out of concern at the lack of availability of adequate assessment and management services for people who may have ADHD and related difficulties.”

“Attention Deficit Hyperactivity Disorder (ADHD) is an internationally recognised, medical condition of brain dysfunction with secondary educational, behavioural and other difficulties. It is frequently associated with excessively oppositional behaviour or conduct disorder, learning difficulties, low self esteem and social skills difficulties, and a wide range of other difficulties.”

Geoff's site gives a list of learned articles on ADHD and recommends an ADHD site. He is a man on a mission, and good luck to him. But is there another side to the story? Not that you would find from Geoff’s site.

Sami Timimi is an NHS consultant psychiatrist. Like Geoff, Sami is an authority on ADHD. He has written a book called: “Pathological Child Psychiatry and the Medicalisation of Childhood”

Dr Crippen started the book yesterday. He finished it today.

Sami presents the other side of the story in a balanced and thoughtful way. And he does not ignore Geoff’s work. He mentions it frequently and discusses it.

As a medical researcher, Sami had concerns about ADHD. He wrote a paper questioning the validity of the ADHD construct. The paper was rejected. It was regarded as blasphemous. And yet, when he presented the paper to several small groups of paediatricians, it was welcomed. His concerns were widely shared.

“So what is the evidence for the existence of this disorder? Is there a medical test that will diagnose it? No. Are there any specific cognitive, metabolic or neurological markers for ADHD? No. ADHD is a cultural construct diagnosed on the basis of clinical opinion and faithful believe of the practitioner and is often presented as if it were a biological fact.” (Timimi)

The paediatrician who came to see us puts children on amphetamine related drugs on the basis of one assessment and a questionnaire filled in by the school. He believes that seven to ten per cent of children should be on such medication.

How does Sami approach children with these problems? There is not space to go into all the details but he describes his approach as “multi-perspective”:

• Slow down the assessment process and engage the system
• Put a lot of effort into trying to engage children and their families
• Take a multi-factorial approach
• Take a slow-process approach to deconstructing the meaning behind a diagnosis of ADHD
• Look for the positives and for the solutions the family have already generated
• Be open and informative and allow the parents to make the decision about medication
• Be prepared to be there in for the long haul
• Be prepared to consider alternative approaches

Geoff Kewley may take this approach as well. I do not know. He is eminent and well-respected. Our local paediatricians do not take this approach. Children are bunged on amphetamines after an assessment that I regard as too short, and I am not happy with the follow up they receive. I am now close to the point of refusing to continue prescribing these drugs on their behalf. I am not obliged to. If I prescribe a drug, I share the responsibility for any problems that arise. If I refuse, it will cause inconvenience to the parents and more work for the hospital, but the prescribing only devolved onto GPs as the result of a cynical, budget-dumping exercise which I have described elsewhere.

Dr Crippen does believe that an ADHD syndrome exists and accepts, with some reluctance, that it may occasionally be necessary to prescribe these unpleasant drugs. He thinks that genuine cases are few and far between. He believes that these drugs are grossly and inappropriately over prescribed. He believes that there is a Big Pharma conspiracy not only to promulgate the drugs but to promulgate the condition itself. He believes that the drug companies cannot be trusted to highlight the side effects of these drugs. He believes that thousands of children are now on these behaviour modifying drugs to suit the convenience of society. His concerns are shared by GPs and many paediatricians the world over. In the USA these drugs have just been "black boxed" - a formal warning of their dangers has been issued:

"An FDA advisory committee narrowly recommended today that a black-box warning about the risk of heart attacks, stroke, and sudden death be added to popular drugs for attention-deficit hyperactivity."

What should you do if you think your child has got ADHD?

If any doctor wants to put your child on these drugs on the basis of a single assessment, then take your business elsewhere. Read about ADHD. Read it up as widely as you can. Who is making the balanced case out there? Look at the drug company sites which advertise these drugs. Ask yourselves if they have any motive other than profit. Then look at the Death from Ritalin site and see if that changes your mind. Read the articles by Geoff Kewley. Above all else, buy, read and re-read Sami Timimi’s book.