Download THE PRESCRIPTION OF STIMULANT MEDICATION TO CHILDREN FOR ATTENTION DEFICIT (HYPERACTIVITY) DISORDER (ADHD)

THE PRESCRIPTION OF STIMULANT MEDICATION
TO CHILDREN
FOR
ATTENTION DEFICIT (HYPERACTIVITY) DISORDER (ADHD)
A WEST AUSTRALIAN PERSPECTIVE
Every child has the right to live and grow free from unnecessary chemical
interference.
Every child misdiagnosed with ADHD and prescribed stimulant medication is
having that right violated.
Governments have a responsibility to protect the rights of children.
ADHD A CONTROVERSIAL TOPIC
ADHD is a controversial topic with a range of views as to its causes and even
to its validity.
At one end of the spectrum are those who believe ADHD has an underlying
biochemical cause that is best treated with medication. They characterise an
individual with ADHD as being abnormally and persistently inattentive,
impulsive and (in most cases) hyperactive to the extent that prevents their
effective functioning. They believe stimulant medication is generally the most
effective treatment.
At the other end of the spectrum are those who believe ADHD is a medical
fiction and the behaviours associated with the condition are either part of the
range of normal human behaviour or caused by environmental factors like diet
or dysfunctional parenting.
My opinion (derived from my experience as a teacher at a boys school and
subsequent reading) is that whilst a small number of children may benefit
from medication, ADHD is frequently misdiagnosed and subsequently many
children are wrongly receiving stimulant medication. I believe these children
are having their right to live and grow free from unnecessary chemical
interference violated.
DIAGNOSIS
There is no commonly used or widely accepted biochemical or physiological
test for ADHD. Whilst treatment is usually biochemical, diagnosis is based
almost exclusively on behavioural assessment.
The most commonly used diagnostic criteria in Australia are the International
Classification of Disease, io" edition (ICD - 10) and Diagnostic and
Statistical Manual of Mental Disorders, 4th edition (DSM - IV).
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4. Often fails to follow through on instructions or to finish schoolwork,
chores or duties in the workplace (not because of oppositional
behaviour or failure to understand instructions).
5. Is often impaired in organising tasks and activities.
6. Often avoids or strongly dislikes tasks, such as homework, that require
sustained mental effort.
7. Often loses things necessary for certain tasks or activities, such as
school assignments, pencils, books, toys or tools.
8. Is often easily distracted by external stimuli.
9. Is often forgetful in the course of daily activities.
Hyperactive
1. Often fidgets with hands or feet or squirms on seat.
2. Leaves seat in classroom or in other situations in which remaining
seated is expected.
3. Often runs about or climbs excessively in situations in which it is
inappropriate (in adolescents or adults, only feelings of restlessness
may be present).
4. Is often unduly noisy in playing, or has difficulty in engaging quietly in
leisure activities.
5. Exhibits a persistent pattern of excessive motor activity that is not
substantially modified by social context or demands.
Impulsive
1. Often blurts out answers before questions have been completed.
2. Often fails to wait in lines or wait turns in games or group situations.
3. Often interrupts or intrudes on others (eg butts into others'
conversations or games).
4. Often talks excessively without appropriate response to social
constraints.
ICD - 10 and DSM - IV both require that symptoms be demonstrated by the
age of 7. This means that any child diagnosed after 7 being retrospectively
diagnosed. Many adults are now being diagnosed and medicated.
Not surprisingly the effect of these techniques is not as dramatic or as
instantaneous as stimulant medication.
MY EXPERIENCE AS A TEACHER
My interest in ADHD stems from my previous employment as a teacher at a
boys' secondary school. The first time I was made aware of the condition was
in 1996 when a clinical psychologist addressed the school on ADHD. The
psychologist defined ADHD sufferers as 5 per cent of children who are the
most inattentive, impulsive and/or hyperactive and that ADHD occurred most
often in boys.
Inattentive, impulsive, hyperactive behaviour is a part of childhood, particularly
for boys. Some children are by their very nature more impulsive, hyperactive
and inattentive just as some children are taller, shorter, heavier, lighter and
less or more coordinated.
To define the 5 per cent of children who are the most impulsive, hyperactive
and inattentive as having a disorder has parallels with defining the shortest 5
per cent of the population as having height deficit disorder.
This argument is often countered by the claim that ADHD is a disorder
because it prevents the sufferers from functioning effectively. There are no
objective measures or even stated criteria for defining effective functioning.
believe that it is often simpler for even well intentioned doctors to diagnose
and prescribe behaviour-altering drugs than it is to deal with the underlying
cause.
The symptoms of ADHD, inattentiveness and hyperactivity, are also the
symptoms of a variety of conditions including:
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•
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Hearing impairment;
Intellectual disability;
Specific learning disabilities;
Autism;
made them more attentive but it had made them more compliant and easier to
manage.
I also know of teachers who with disturbing certainty categorised particular
students as undiagnosed ADHD. In my experience, these were teachers who
had particular difficulty with high-spirited students. ADHD is a condition whose
diagnosis is necessarily subjective, as there can be no objective measure of
impulsiveness, hyperactivity or inattentiveness. I would suggest a visit to any
schoolyard at recess or lunchtime will reveal just how normal impulsive and
hyperactive behaviour is.
My suspicion that ADHD drugs are over-prescribed first arose because of my
experience with one student who as a 15-year old had his first "drug free
period" in many years when he failed to self-medicate on an extended school
camp.
This boy for his three previous years at school had been withdrawn and
passive, to the extent of almost complete social isolation. After a few days
without medication, he began to participate and socialise with other students.
For the first time, his peers and teachers witnessed his personality and sense
of humour. After the camp, the boy was immediately put back on medication
and for the rest of the time at school he continued to be withdrawn and
socially isolated.
I knew of several other boys on ADHD medication who where similarly
socially withdrawn.
WEST AUSTRALIAN EXPERIENCE
It can be argued that I know of only a few isolated cases of misdiagnosis and
over-prescription. It is, however, much harder to dismiss the July 1996 Report
of the Technical Working Party on Attention Deficit Disorder prepared by
twelve Perth health professionals, including five doctors and four
psychologists. Whilst the report stated that stimulant medications are effective
in 85 per cent of children carefully diagnosed as having ADHD, it identified
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It concluded that "the differential rate of prescriptions may be more reflective
of the prescribing patterns of paediatricians servicing the various areas than it
is of social or other factors associated with ADHD in those areas".
The report was first published for public comment in July 1996 before a final,
slightly watered down report was presented in April 1997 to a cabinet
subcommittee consisting of the then Ministers for Education, Health, Disability
Services and Family and Children's Services. Both reports contained similar
recommendations, most of which have not been implemented.
A key recommendation of both reports was: "That the Stimulants Committee
of the Health Department be authorised to carry out random audits into the
use of bloc authorisations; and that paediatricians and psychiatrists found to
be failing to abide to the appropriate criteria have their bloc authorisation
capacity removed".
This has not happened. Currently, those paediatricians and psychiatrists who
prescribe the most are assumed to be competent and are given "bloc
authorisations" for the prescription of dexamphetamine and/or
methylphenidate. Effectively, this means the heaviest prescribers are the
least accountable. In my opinion, this is exactly the opposite of how the
system should work.
The problem of bloc authorisation continues. I believe making doctors
accountable on a case-by-case basis for the prescription of stimulant
medication is essential to dealing with the problem of over prescription.
Since the Technical Working Party report was prepared in 1996 the rates of
diagnosis and prescription have continued to skyrocket.
The rate of prescription of stimulant medication in Western Australia in 1996
was less than 1 per cent (1.6 per cent of boys and 0.15 per cent of girls). The
draft September 2000 report prepared by the Western Australian Mental
Health Division titled Attentional Problems in Children and Young People
stated "Over 3.7 per cent of Western Australian children under 18 years are
on stimulant medication with most of these young people being treated for
ADHD"
Medication must not be used as a means of masking symptoms of underlying
causes.
The following suggestions are offered as a means of minimising misdiagnosis
and over-prescription.
1. The end of bloc authorisation for the prescription of stimulant
medication so that prescribing doctors are accountable on a case-bycase basis.
2. A mandatory six-month "cooling off' period between the diagnosis of a
child as ADHD to allow the trial of non-biochemical strategies to
address the behaviours characterised in ADHD.
and
3. Government support for ADHD support groups, which offer drug free
strategies to parents and children to deal with the symptoms of ADHD.