Does your child really need Ritalin?
Prescriptions for Ritalin have doubled in the the last decade for children diagnosed with Attention Deficit Hyperactivity Disorder but is this chemical cosh an easy option when it should be the drug of last resort
Ben Napier wasn’t your typical ADHD child, more of a daydreamer than a misbehaver, remembers his mother, Pauline. 'He’d forget to hand in his homework, even though it was in his bag and have trouble understanding instructions or copying anything down off the board,’ she says. 'He was struggling at school and I knew something was wrong.’ When Ben was 12, his teacher recommended Pauline take him to see a doctor.
After a two-year process of assessment, Ben was finally diagnosed with Attention Deficit Hyperactivity Disorder (ADHD). Though Ben was relieved, 'I know I’m not stupid now,’ his mother was heartbroken. 'I felt powerless,’ says Pauline. By way of help, the only option offered to Ben was the medication methylphenidate, otherwise known as Ritalin, which works by stimulating a part of the brain that modifies mental and behavioural reactions. 'There was no offer of behavioural or parenting support, nothing,’ says Pauline. 'I felt it was my only option. It’s a terrible decision to have to make; to medicate your child.’
NHS figures issued in August this year show that almost a million prescriptions (922,000) for Ritalin were handed out last year, a figure that has more than doubled in the last decade. It’s prompted concern from experts about doctors over-prescribing the medication to youngsters for attention deficit hyperactivity disorder or ADHD, which affects around five per cent of school children, most of them boys, and is characterised by poor memory and concentration and high levels of impulsiveness.
Guidelines from the NHS watchdog, the National Institute for Clinical Excellence (NICE) say drugs should only be used as a last resort – and only in the most severe of cases - after parenting programmes and behavioural therapies. But the evidence suggests this is not the case.
"These professionals are opting for what’s easy to give – a prescription that clearly does work to improve a child’s attention - but this shouldn’t be the first port of call," says Professor Tim Kendall, consultant psychiatrist and director of the National Collaborating Centre for Mental Health at the Royal College of Psychiatrists, who helped draft the NICE guidelines for the treatment of ADHD. For example, he says, parent training programmes are shown to work in the treatment of ADHD. "But, they’re simply not being offered."
'These drugs are being used as a quick fix,’ says David Webster, treasurer of the Association of Educational Psychologists (AEP) who have lobbied the Department of Health about the over-prescription. "There is evidence that it is being prescribed to children as young as three and that it’s being administered to children with mild to moderate ADHD, as opposed to severe as the NICE guidelines state."
So, are we medicalising what is essentially typical children’s behaviour - naughtiness, tantrums, inability to sit still? "Maybe not medicalising, but certainly medicating," says Professor Kendall. Critics argue that while the tablets may lead parents to think that something is being done, essentially the tablets don’t cure anything.
Yes, they may improve cognitive function and calm the child down a little bit, but they don’t teach the child strategies on how to live successfully with the condition. Indeed, a Colorado University study in 2010 showed that when 150 adolescents diagnosed with the disorder were given sessions of CBT plus a sugar pill they were told was Ritalin, their ADHD symptoms disappeared just as well as 150 adolescents who were given both the therapy and actual Ritalin-type drug.
In the US, there is something of a Ritalin free-for-all with the Centre for Disease Control and Prevention claiming that over 10,000 toddlers were on the drug in 2014. Moreover, anecdotal reports suggest a bourgeoning black market for the drug across the world. It’s believed the demand may be fuelled by anecdotes that 'using’ the drug can give the edge during exams - although no solid evidence for this exists as yet.
Professor Kendall cites stories of patients who were able to get Ritalin from an Indian website simply by filling in a questionnaire and research in the US has found that a quarter of adolescents who have a prescription for ADHD medication either share or sell it to their peers.
Fears have also been raised over other side effects of Ritalin, including severe weight loss, tics, liver damage, insomnia and stunted growth. 'These drugs have a direct effect on the production of growth hormone,’ says Professor Kendall. "If a child takes methylphenidate [Ritalin] for a year, they will lose three quarters of an inch of expected growth."
Other side effects include mood swings, anxiety, depression and suicidal thoughts and in 2009, the EU regulator, the European Medicines Agency said all patients should be monitored for psychiatric symptoms during treatment with Ritalin-type drugs.
For Joanne,* a Liverpool mother whose son Jack was prescribed Ritalin when he was 11, she saw a completely different child emerge after just two weeks on the drug. "Suddenly he became emotional, crying a lot and very clingy," she remembers.
"He became frightened and anxious and would wait for me outside the toilet door crying and saying 'What if the dog died? What if the cat died? What if something happened to granddad?’"
"It was terrible, because on one hand, I was getting calls from school saying 'his concentration is amazing, he’s learned this, he’s learned that,’ so my child was finally getting the praise he’d never had from his teachers, but his personality was completely different."
Jack seemed fine during the day, remembers Joanne, "but once the drug wore off in the evenings, he was an emotional mess." When he started experiencing suicidal thoughts, she took him to the consultant who took him off the Ritalin that day.’
The main issue is getting a proper diagnosis, says Dr Mina Fazel, consultant child psychiatristsand researcher at Oxford University who conducted a clinical review into the treatment of ADHD published in the British Medical Journal in May this year. Unfortunately with child mental health services stretched to their limits – and depending on where you live – this may take anywhere from three months to four years. "This can’t be done with just one visit," she explains.
"We need input from a number of people to rule out other conditions.’ For example, some 40 per cent of children diagnosed with ADHD have anxiety and mood disorders which can be made worse by medications such as Ritalin.
For Pauline Napier’s son Ben, now 17 and still on a Ritalin-type drug, there’s no doubt that medication has helped his grades.
"He started in the bottom set for maths with a predicted D grade and after going on Ritalin went into the top set and got a B. In English, he dramatically improved too."
But there has been a downside, Pauline says. "He lost a huge amount of weight, leaving him awfully thin which was horrendous to see. And he needed a lot of emotional support too, which we’re not sure was down to the drugs or things like exam stress." But most upsetting for Pauline, she explains, was the drug’s effect on Ben himself. "Yes, his concentration improved hugely but in school he was a lot quieter - he said on it, he just doesn’t feel quite himself."