Generation Ritalin

Doctors are at odds over the treatment of children affected by ADHD … to drug them or not to drug them?

Michelle Wiese Bockmann reports.

At the age of 10, Brandon Frances screamed for hours on end, suffered psychotic episodes and daily beat his mother.

A pediatrician in Perth diagnosed Brandon with attention deficit hyperactivity disorder when he was four, and for the next seven years he was constantly medicated with a cocktail of up to six different drugs to control his behaviour.

Now 13, Brandon no longer takes the medication, is behaving and doing well at school. Eighteen months ago doctors at a Perth public hospital clinic found Brandon did not have ADHD, but a learning disorder. His entire treatment was changed.

“Medication was killing my son,” his mother Katherine says. “Medication was causing him to have psychotic episodes. He did not have the disorders, the disorders developed because of the drugs he was taking.”

ADHD is loosely characterised as persistent and severe inattention, hyperactivity and impulsive behaviour. It is one of Australia’s most commonly diagnosed and fastest-growing disorders among school-aged children. After the US – where six million have been identified as having the disorder – and Canada, Australia has the world’s highest proportion of children diagnosed with it.

Australian studies estimate between 2.3 per cent and 6 per cent of children around the country have the disorder. Its cause is unknown, but genetic, cognitive, neurophysiological, family and environmental factors are thought to contribute. There are no clinical or medical tests to diagnose it.

How the medical community is managing and treating ADHD is fiercely contested. And last month it killed off the career of a pediatrician who specialised in the treatment of children in Adelaide and Perth.

Harry Nash retired last month, tired of a decade-long battle with a cluster of Adelaide doctors who repeatedly complained to the medical board about the prescriptions he has given ADHD children. The group represents many of those in the medical fraternity who believe the condition is widely misdiagnosed.

They are also horrified about so-called polypharmacy – the prescribing of multiple drugs in young children to treat ADHD and related disorders. In some cases, children – such as Brandon – as young as four have been prescribed adult doses of powerful, psychotropic drugs for their conditions.

Support groups, doctors and parents are also questioning the quick-fix solution provided by stimulant drugs such as dexamphetamine and Ritalin.

These drugs, prescribed to calm and focus ADHD children, are at the frontline of treatment. Yet teachers have described students in classrooms in a zombie-like state, stoned on drugs.

Between August 2003 and July 2004, 305,638 prescriptions were written for dexamphetamine and 208,235 scripts were issued for methylphenidate, commonly sold as Ritalin.

Yet there are some parents who argue their ADHD children must remain medicated, such as Judith Naylor-Vane, the Adelaide mother of 13-year-old Timmy.

Nash diagnosed Timmy with ADHD when he turned three. Before Timmy began school he was taking anti-depressants and dexamphetamine. Today, he also takes benzodiazepine for anxiety, and Clonidine to sleep. Concerned about dangerously high levels of drugs prescribed by his pediatrician, hospital psychiatrists tried to detoxify Timmy a few years ago. Doctors also complained to the medical board in the late 1990s about how Nash was treating Timmy without his mother’s knowledge.

“They took him off the drugs but over time they put him back on everything,” says Naylor-Vane.

When he was off drugs “he went straight back to panic attacks, going into himself; you couldn’t reach him”.

Taylor-Vane says Timmy has ADHD, features of autism, obsessive-compulsive disorder, different phobias, problems sleeping and many anxieties. This co-morbidity – having different disorders alongside ADHD – is not uncommon.

About 50 to 80 per cent of children diagnosed with ADHD also meet the criteria for at least one other disorder, such as oppositional defiance disorder, conduct disorder and Tourette’s syndrome, according to the Learning and Attentional Disorders Society of Western Australia.

Nash says he was hounded from his job because he supports prescribing multiple drugs for children such as Timmy.

“They often have depression, so you need to treat that,” Nash says. “And if there’s an anxiety disorder, that needs to be treated too. You have to treat each disorder separately.”

Until his retirement, Nash was one of a small group of specialist pediatricians around Australia operating clinics to treat ADHD.

Prominent South Australian child psychiatrist Jon Jureidini, head of the psychological medicine department at Adelaide’s Women’s and Children’s Hospital, is one of their chief critics.

He led complaints against Nash before the Medical Review Board of South Australia. “They are responsible Australia-wide for the vast majority of poly-pharmacy and high-dose prescribing and those who adopt that approach tend to do it in a lot of kids,” he says.

Doctors are allowed to prescribe so many drugs for children because “you don’t have to prescribe according to the guidelines … I guess it shows a flaw in the medical system that that can happen,” Jureidini says.

He dismisses suggestions ADHD is a disorder. “I just don’t think that it is right that there are that many children around who have four or five different things wrong with them,” he says.

“So when you have got a kid with ADHD and oppositional defiance disorder and depression and anxiety disorder and stuff, what this says is not that he has got four disorders, but that there is something wrong with the kid and people haven’t properly understood what it is yet.” Jureidini says in some cases, abuse or neglect may be 100 per cent responsible for children’s behaviour. In other cases, parenting has very little to do with it.

The president of Australia’s Hyperactivity Attention Disorder Association, Julie Appleton, reacts testily when told of claims from child psychiatrists such as Jureidini that ADHD is not a disorder.

“For God’s sake, which part of the Ark did he get off?” she asks.

Appleton says parents should first check children’s diets for food intolerance and allergies, many of which are not found in junk food, but from foods with naturally occurring chemicals such as tomatoes and orange juice.

Only when this has been ruled out should parents look at options such as medication.

“This is 2005, we are not scared of medication,” Appleton says. “What we are scared of is the incredible depression in children that comes from these problems [having ADHD] because they are ostracised at school and not socially acceptable.” The highly emotional and controversial debate about treatment has featured at state and federal parliamentary inquiries, among hospitals and at medical board hearings around Australia. A parliamentary report in Western Australian last October concluded it was not clear whether ADHD was the cause of dysfunction in children, or whether it was the result of family or other dysfunction. It concluded up to three-quarters of affected children may have been wrongly diagnosed.

Western Australia has the highest number of prescriptions dispensed for dexamphetamines at three and a half times the national average. A federal parliamentary library study of prescribing rates reached no conclusion for this disparity but said: “It appears that Australia still has some distance to go before achieving best practice in the prescribing of medication for the treatment of ADHD.”

The National Health and Medical Research Council last issued guidelines for ADHD treatment in 1997. It recommends the short-term use of stimulant medication as safe and effective, and part of any management plan. But the NHMRC says medication should be used with caution among toddlers and pre-schoolers. Expert opinion should be sought when multiple drugs are considered to treat other co-morbid conditions. Counselling and education for families and children should be part of treatment alongside medicine, it says.

But this view is under attack. A drug effectiveness review by Oregon State University in the US was released this week into the effectiveness of ADHD stimulant drugs and found little evidence they were safe, effective or boosted children’s performance at school.

It’s a view heartily endorsed by parents such as Katherine Frances, angry she went through years of hell because her son was wrongly diagnosed and placed on so much medication.

“If my child, who they [doctors] thought would always be medicated can survive and do better without medication then I think all children should be given the opportunity Brandon has been given,” she says.