Wednesday, 19 November 2014

Re: 'Why are we failing young patients with ADHD?' Iain McClure, BMJ Response

Views & Reviews Personal View

Why are we failing young patients with ADHD?
BMJ 2014; 349 doi: (Published 13 October 2014) Cite this as: BMJ 2014;349:g608

Re: Why are we failing young patients with ADHD?

16 November 2014: Iain McClure, consultant child and adolescent psychiatrist,NHS Lothian Royal Hospital for Sick Children, Edinburgh, EH9 1LF, UK 

"Simon Bowers correctly states that few geographical areas offer clinical pathways that include holistic interventions for ADHD (1). He argues for ‘a definitive diagnosis’ and ‘evidence based treatments’ from the outset, but the reality is that ADHD is such a confused, over-simplistic and, consequently, over-diagnosed disorder, that it cannot deliver the certainty that health managers understandably expect on behalf of tax payers.

Instead, the failure of ADHD research to deliver a valid and reliable concept of impairment within the condition, means that, all too often, children diagnosed with ADHD are prescribed stimulant medication from the outset, whether their condition is severe, moderate or mild (2,3). In all likelihood, these patients, once prescribed stimulant medication, will continue to take it throughout their primary and early secondary school years, with increasing numbers remaining on it into adulthood. Because of the increasing pressure on doctors in community paediatric and child psychiatric clinics, many of these patients will not receive a 'drug holiday' from this medication throughout these years, despite the advice of guidelines (2). This situation contrasts starkly with mainstream general adult psychiatric practice, regarding antidepressants or antipsychotics, in which doctors expect to at least attempt a withdrawal of such medications, once the patient has remained clinically well for several months.
One of the anomalies of ADHD compared to other psychiatric conditions, is that it appears to offer no recovery concept, except stabilisation on medication. Why is this? Usually, such a scenario only arises in those child patients who have life-threatening conditions, such as asthma, epilepsy or cystic fibrosis. Yet we know that ADHD is not life-threatening and that there is no evidence that stimulants reduce the long term problems associated with the severe form of the condition, let alone the milder forms (2,3).
The current, apparently inevitable trajectory of ADHD diagnosis and consequent long-term medication for moderate, or even mild cases, accretes associated issues, such as disability and carer benefits, which gain supertanker momentum. Given the pressure which doctors are under to accommodate this powerful system, services fail to develop the alternative strategies which Simon Bowers is asking for. Even if Clinical Commissioning Groups do have the transformational clout to look at this situation with ‘a fresh perspective and a determination to do things differently’ (1), are there sufficient numbers of qualified (and, more importantly, motivated) clinicians who can run psychological group treatment programmes (which is what NICE recommends should be the first line treatment for moderate ADHD(4))?
To really tackle this problem, we need to completely dismantle the ADHD concept and generate something which more accurately describes children and adolescents, their thoughts, feelings and behaviour, the families they live in and the social systems around them, all within a nurture, as opposed to a disorder, concept.
At the very least, clinicians, health managers and guideline bodies such as NICE and SIGN should challenge the ADHD industry (academic and pharmacological) to produce a disease concept which accurately describes levels of severity (which, for example, autism science has achieved). Only if such evidence emerges, will health and local authority managers be able to attempt to develop multi-agency pathways which accurately meet the needs of these vulnerable children and young people.
However, given that the drug industry for ADHD in the USA alone was worth $9 billion annually in 2012 (and continues to increase) (5) any such progress seems a distant prospect. Perhaps the best way to get full value out of the Liverpool pound is to withhold it."
1. Why are we failing young patients with ADHD? Bowers, S. BMJ 2014;349:g6082
2. Prescribing methylphenidate for moderate ADHD. McClure, I. BMJ 2013;347:f6216
3. Attention-deficit/hyperactivity disorder: are we helping or harming? Thomas, R, Mitchell, GK, Batstra, L. BMJ 2013;347:f6172
4. National Institute for Health and Care Excellence. attention deficit hyperactivity disorder. QS39. 2013.
Competing interests: I am Chair of the review of the SIGN guideline on Autism Spectrum Disorder and a member of SIGN's Guideline Programme Advisory Group.

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