The Challenge of ADHD…

There has been an irritating shortage of methylphenidatemedicines used to treat ADHD as manufacturers struggle tosatisfy demand.   The NHS waiting list for an ADHD referral is in the region of 7 years so it’s unsurprising many patients who think they might have the condition are seeking out private practitioners to gain a diagnosis.   This can then create conflict with GPs unwilling to accept private–practicediagnoses given the drugs they are being asked to prescribe are controlled with potentially significant side-effects.

Since 2015 the prevalence of Attention-Deficit-Hyperactivity-Disorder (ADHD) in the UK has tripled.  That’s a big increase and begs the question why?     There is little doubt people present with symptoms that are sufficiently severe to impairpersonal development and normal social functioning but do these symptoms always justify an ADHD diagnosis?  There is a view that an ADHD diagnosis provides a label; a get–out-of–goal–free card and individuals then cling tightly to this unwilling to change when change might be the simplersolution.

Technology is being blamed and certainly children and young adults who have taken to life on-line are bombarded withconstant stimulation.  Johathan Haidt in his recent best seller The Anxious Generation, identifies studies that show young adults who are constantly stimulated by social media are more likely to have a diagnosis of ADHD.   Attention is a key element of a healthy Pre-Frontal Cortex, the last part of the brain to develop.   Attention is fragmented by constantly altering stimuli and the child becomes unable to make and execute plans.   It is the curtailing of social media, especially smart phones, that is needed, according to Haidt.  Indeed, Australia has recently taken this step as have many UKschools of their own volition yet it’s too early to say how that impacts the prevalence of ADHD.

The Diagnostic and Statistical Manual of Mental Disorders, or the DSM, is the definitive guide on mental disorders for healthcare professionals. Since the 1980s, it’s provided clinicians with diagnostic criteria for ADHD, but it wasn’t until 2013 that it updated its definition of ADHD to include adult ADHD.  Before the mid-1980s ADHD didn’t reallyexist, certainly as a diagnosis, but challengingly behaved children did and indeed in those years I had one.   I did oftenlook at this tender child and wonder what made him do thethings he did.  It never entered my head that he could besuffering from a disease let alone seek out medicines that might bring his behaviour back more in line with what we think as normal.     Thirty years on, I don’t feel any guilt that we were negligent or failed this child.  On the contrary I am proud to say he has grown into a totally responsible adult; married, taken on a mortgage and holds down an impressive job in IT.   Had we presented him to a competent psychologist or psychiatrist he might well have been given an ADHDdiagnosis and spent his childhood on Ritalin.  

The symptoms currently listed are; inattention, poor planning, hyperactivity, short attention span and impulsivity.   These must be pervasive which means the patient must have these in all settings; at home, at school, at play. My son would have ticked all these boxes.    But was his behaviour such that it needed to be pathologized or was he just an outlier in the behaviours that make up the human condition?  

In our capitalist society there is always a tendency to find new markets and ADHD has offered up a goldmine for private practitioners and drug companies.   Also, and interestingly,there has never been a stigma associated with an ADHD diagnosis as there is with other mental health conditions.   Indeed, many social influencers and celebrities are happy towear the label.

We have three things converging; (1) a broader and loose diagnosis, (2) diagnosis creep – doctors fine it easier to diagnosis and (3) a medicine that treats the condition,

A number of high–profile doctors have expressed concern about the surge in ADHD diagnosis.  These include ProfessorSimon Wessely, former President of the Royal College of Psychiatrists, Dr Iona Heath, former President of the Royal College of GPs and Dr Max Pemberton, psychiatrist and medical writer.   They point out that it’s a doctor’s responsibility to resist the drive to over diagnosis and over treat patients.  It is suggested other health professionalsremain quiet, fearful of a backlash from social media. One thing you should never do is suggest that ADHD is a made-up disease currently trending and making a diagnosisfashionable.  Such a suggestion would bring severe punishment and brutal recrimination that might last a life-time.

On-line anyone can complete an ADHD questionnaire supported by private clinics.  This I have done.  It asks; Am I easily distracted? Well, yes.  Am I often late for meetingappointments?  Do I regularly forget appointments? Yes, yesand yes.  By the end of this twenty–minute questionnaire I was being offered an appointment and being reassured that my problems would soon be over.

With a diagnosis comes the prescription.   The main stay of treatment are the psychostimulants; amphetamines ormethylphenidate but the evidence on benefits and harms is to say the least uncertain.   Of 212 trials, assessed in one meta-analysis, 191were deemed to be at high risk of bias mainly due to the difficulty blinding the medicines – you can’t get a placebo medicine that gives the same effects.    Oh, and did I mention most the studies were sponsored by the Drug Industry.

Methylphenidate may be associated with an increased risk of adverse events considered non‐serious, such as sleep problems and decreased appetite. However, the certainty of the evidence for all outcomes is very low and therefore the true magnitude of effects remains unclear.  With these drugs I am always concerned with cardiac effects.

Talking therapy has been shown to be as effective as medication in improving ADHD symptoms and overall functioning levels. The NHS has currently more of a shortage of this option than the medicines.  Some studies have shown that fish oils are helpful. What’s more, they’re safe and well-tolerated. However, the results of these studies have been mixed – some children get better, others get worse.

A practicing social worker with 35 years-experience in children and adolescent services has recently commented that he too is concerned by the surge in diagnoses.  He pointed out that the vast majority of children in care come from chaotic households and these children were much more likely to be diagnosed and medicated.   He did not find the medicines made much improvement but he did find improvement with challenging behaviours when carers were able to establish; set routines, improve nutrition and significantly reduce time on electronic devices.

There are other options to stimulant drugs but these require support which is also in short supply and is claimed to be much more expensive.

I am a pharmacist in Belfast.