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24 September 2008 - The Scotsman - Children's drug Ritalin 'should only be last resort'

Shan Ross

RITALIN, the controversial drug used to calm hyperactive children, should be avoided wherever possible and not given at all to the under-fives, according to new health guidelines due to be released today.

Instead of the drug sometimes dubbed "the liquid cosh", parents should be taught psychological techniques for changing the behaviour of disruptive children diagnosed with attention deficit hyperactivity disorder (ADHD).

Methylphenidate, better known as the stimulant Ritalin, and other drugs should be reserved for severe cases only after other options have failed, health professionals were told.

The drug has attracted fierce criticism with claims it can have side-effects such as hallucinations, cardiovascular disorders and prompt suicidal thoughts.

The guidelines were issued by the National Institute for Health and Clinical Excellence (Nice) and the National Collaborating Centre for Mental Health. They aim to provide a blueprint of best practice for identifying and treating children with ADHD in England and Wales and combat excess use of drugs.

The Scottish Intercollegiate Guidelines Network (Sign), the agency in Scotland that determines policy towards conditions such as ADHD, said it was examining the Nice guidelines ahead of its own new guidance due out next year.

A Sign spokesman said: "This Nice guidance does not have automatic status in Scotland, but it will be taken into account when the Scottish Intercollegiate Guidelines Network updates its existing guidance on ADHD. In writing our guidelines, we analyse the most up-to-date and robust evidence available. The guideline is expected in the first half of next year."

No-one knows exactly how many children in the UK are taking Ritalin, but it is estimated that up to 3 per cent of school-age children and young people are affected by ADHD in the UK. In a school of 1,400 children, there are likely to be ten who are severely affected by ADHD and may qualify for drug treatment under the new guidelines.

It has recently been recognised that around 2 per cent of adults also suffer from the problem. Previously, they were often wrongly labelled as having a personality disorder or some other psychological condition.

The causes of ADHD are unclear, but thought to include both genetic and environmental influences. Diet may be involved and a link with fizzy drinks has been suggested. Problems in the womb or birth trauma could also cause damage in the brain leading to ADHD.

Children with the disorder are always on the move, running, climbing or jumping, as if driven by a motor that cannot be switched off.

Dr Tim Kendall, a consultant psychiatrist from Sheffield who is joint director of the National Collaborating Centre for Mental Health and helped draw up the guidelines, said: "Quite commonly, people tend to revert to offering methylphenidate or atomexitine. When they do that, it's not always because there's a good balance of risk and benefits. It's because the child has got what appears to be ADHD and that's what's available. It's easier to prescribe a drug when other options, like parent training programmes, are not available."

Dr Kendall said it was important to diagnose ADHD correctly. Unlike in the US, where up to 10 per cent of children are said to have ADHD, the test in the UK is whether or not the condition causes real impairment at school and at home.

"It's a pervasive problem," said Dr Kendall. "It's there all the time and it's associated with quite significant impairment."

However, Dr Alex Richardson, senior research scientist at Oxford University and a director of the charity Food and Behaviour Research, said the Nice guidelines did not go far enough.

"It is all very well recommending behaviour programmes for parents of children with difficulties, but this sort of help can be extremely hard to access," she said.


GRACE Mitchell's childhood was blighted by constant disruption and tension at home caused by her undiagnosed ADHD. She was bullied at school in Dolphinton, South Lanarkshire, and left aged 15 with no qualifications.

Two years ago, Grace, now aged 18, was diagnosed with ADHD by a doctor at their new home in Auchinleck in Ayrshire and prescribed Ritalin.

She now has a clutch of Highers and her ambition is to train as a child psychologist.

"My mum got no help at all when I was younger and we were living in Lanarkshire," she said.

"The doctors told her my behaviour was due to bad parenting. One doctor told me: 'If you were older they'd have locked you up.'

"I used to attack my mother and was violent if I couldn't get my own way.

"My mother tried everything - she gave me a healthy diet and cut sweets right back, but it made no difference."

Grace added: "I said to myself: 'If it (Ritalin] makes me better, give me a chance.' I'm now calm and can focus."

How the drugs add up


Schoolchildren diagnosed with ADHD in Scotland, according to NHS Quality Improvement Scotland.


Under-18s estimated to have ADHD in Scotland, but who have not been identified as such.


Children with the most severe form of ADHD in Scotland but who have not yet been diagnosed.


Of school-age children have been diagnosed as suffering from ADHD in Scotland.


Prescriptions for ADHD treatments handed out in Scotland in 1996.


Of school-age children thought to have ADHD, according to international studies.


Of cases of ADHD in Scotland where Ritalin was recommended as the "first-line" treatment.


Prescriptions for ADHD treatments, such as Ritalin, handed out in Scotland from 2006 to 2007 - or 163 every day.