http://www.newscientist.com/channel/opinion/mg19025451.800
IT SOUNDS like a mad idea, but it works. Take children who are unruly and unable to focus on their schoolwork, and give them amphetamine-like stimulants. Far from making them bounce off the walls, the drugs can turn little terrors into attentive students.However, the idea of prescribing drugs related to addictive illegal stimulants has always caused concern – all the more so given the escalation in diagnoses of attention deficit hyperactivity disorder (ADHD), the condition the drugs are supposed to treat. Now reports are coming in of serious adverse reactions, including hallucinations and, in rare suspected cases, sudden death from cardiovascular problems (see “Hyperactivity drugs are out of control”).
For the benefit of concerned parents, it is important to put the risks and benefits into context. ADHD is a socially and educationally debilitating condition, and places children at higher risk of serious accidents. The success of stimulants such as methylphenidate in treating ADHD is unprecedented in psychiatry. Unlike antidepressants, which work well in only about half of those who take them, methylphenidate is highly effective in most children and young adults with ADHD. Against these benefits, we now have 25 cases of sudden death from heart problems, and reports of hallucinations in up to 5 per cent of those taking the drugs.
These adverse events certainly need further investigation, and merit changes to the drugs’ labelling so that doctors and patients can see the risks. Yet on existing evidence, the drugs should not be demonised. Instead, we should make sure that they are only given to children who actually have ADHD, because that is where the main problem lies. Proper diagnosis requires extensive behavioural observation, ideally in different contexts. Some kids are unfocused and unruly at home, yet can buckle down at school with a good teacher. Medicating kids because of bad parenting is a bad idea.
Some 10 per cent of 12-year-old boys in the US, where diagnosis of ADHD is more common than in most other countries, are being treated for the condition. The true incidence of the disease may well be very high, but these figures conceal widespread misdiagnosis. Many children who do not have ADHD are prescribed the drugs after woefully short consultations, often by family doctors under pressure from parents who want their children to compete in the classroom. Yet other youngsters who have ADHD are not getting the treatment they need.
This in microcosm is what is wrong with the US healthcare system, which tends to over-medicate those who have health insurance, leaving the rest to make do with healthcare that would embarrass some developing countries. Even so, the situation with ADHD is particularly worrying, as both over-medication and under-medication could lead to future drug dependency. Children with untreated ADHD are known to be at greater risk of later drug abuse than those on medication. The impact of giving stimulants to healthy kids is unknown, and difficult to study. Despite efforts by manufacturers to formulate pills to release their active ingredient slowly, minimising their addictive potential, the fear remains that today’s prescribing practice may be priming millions of children for drug-dependency problems.
In this context, the decision last week by advisers to the US Food and Drug Administration not to back an application to market a drug for ADHD called modafinil has caused some disappointment. Modafinil should not be addictive, but the FDA’s advisers were concerned about a case of a serious skin condition in a clinical trial, and have asked for further studies. The FDA advisory panel’s caution is appropriate. Yes, we need other drugs to treat ADHD. But first we must be sure they are safe, and are only given to children who really need them.
