Imagine a neurological condition that affects one in 20 under-18s. It starts early, causes significant distress and pain to the child, damages families and limits the chances of leading a fulfilled life as an adult. One in 20 children are affected but only half of these will get a diagnosis and a fifth will receive treatment. If those stats related to a familiar and well-understood illness, such as asthma, there would be little debate about the need to improve intervention rates. But this is attention deficit hyperactivity disorder (ADHD), and the outcry is muted. If anything, we hear warnings that too many children are being labelled this way, and too many given prescriptions.
In the United States, ADHD is diagnosed at more than twice the incidence in Britain. The true prevalence is likely to be the same on both sides of the Atlantic. So what’s the story? Is the US too gung-ho, or is the UK dragging its heels? Are American doctors too quick to medicate children, or British doctors too slow?
Emily Simonoff, co-author of a new meta-analysis in the journal the Lancet Psychiatry, says the problem in the UK is “predominantly about undermedication and underdiagnosis”. Her study examined a range of drug treatments compared to placebo, and it shows that methylphenidate (better known by under the brand name Ritalin) works best for children and amphetamines for adults.
It can seem counterintuitive that stimulants work for ADHD. In fact, both treatments are thought to increase the activity of the chemicals dopamine and noradrenaline in the brain, neurotransmitters that play a role in executive functions such as learning, planning and exerting control over our behaviour and thoughts. The side-effects such as agitation, weight loss, sweating, sleep disturbance and high blood pressure can occur whether you take the drugs for ADHD or recreationally. The difference is that people with ADHD are more likely to benefit, and prescribed doses are carefully controlled and monitored. As an NHS GP, I can only prescribe these drugs using a special protocol that lays down follow-up arrangements. The idea that we dole them out in a cavalier manner is just not true.
ADHD isn’t some sort of catch-all term for bad behaviour, but a clearly identifiable set of symptoms (including inattention, impulsivity and hyperactivity), with strict diagnostic criteria and evidence-based treatment options. People with neurodevelopmental disorders such as ADHD, autism, dyslexia, dyspraxia and dyscalculia have brains that are structurally and functionally different to those of neurotypical people. It’s a widespread misconception that ADHD equates to disruption in classrooms; a more common presentation is anxiety and difficulty with learning. “A kid with ADHD may be well-behaved and academically able,” says Tony Lloyd of the ADHD Foundation. Identifying that there is a problem and providing the right support is critical.
So where does the scepticism about ADHD come from? Perhaps it’s an understandable reluctance to label kids while they are still developing, or a wariness about medicalising normal variation in behaviour. Oftsted’s chief inspector, Amanda Spielman, speaks for many when she voices concerns that the drugs used in the treatment of ADHD are a “chemical cosh”, are overprescribed and disguise bad behaviour that should be managed in other ways.
There is no doubt that rates of prescription for ADHD in the UK have risen significantly since the 1990s. The prospect of a US-style situation in which one in 10 children aged two to 17 (rising to one in five boys aged 14 to 18) are diagnosed with ADHD, and two-thirds of those diagnosed are on medication, raises justifiable questions. But this scenario is a long way from the reality in the UK, where the NHS imposes vigorous diagnostic guidelines and, crucially, there are no financial incentives for NHS doctors to write prescriptions.
Caution about the action of psychoactive drugs on developing brains is entirely appropriate. The short-term safety data we have is reassuring, though more research is needed into long-term effects. But this caution has to be weighed against the harms, if other treatments aren’t suitable or effective, of doing nothing. Without diagnosis and treatment, children become prone to anxiety, self-harm and school failure. Around a third will continue to have problems into adulthood and some people will only be diagnosed once they are adults.
Earlier this year a Demos report highlighted the social and economic cost to society of adult ADHD, as impulsivity, poor concentration and risk-taking behaviour interfere with work and relationships. The inability to regulate emotions and tendency to become overloaded by external stimuli has been described as “like driving a Ferrari with bicycle brakes”.
Treatment for ADHD doesn’t always or only mean medication; the National Institute for Health and Care Excellence’s guidelines recommend a multimodal approach including support for parents, cognitive behavioural therapy (CBT) and stress-reduction strategies. Lloyd says the Nice guidelines are great but mostly aren’t being followed. My experience as a GP would certainly back that up. Children tend to be seen quicker than adults, but often the only treatment given is medication, with other interventions such as parenting support and CBT failing to materialise.
The cautious UK approach to ADHD may be preferable to the more enthusiastic US one. But it would be a shame to let scepticism get in the way of good medicine. And that means casting aside any doubt that ADHD is a medical condition, and demanding funding for a range of treatments, including but not limited to drugs. Unfortunately, it seems that is still a long way off.