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| IMPULSIVE(ADHD) OR JUST DISILLUSIONED(ANGRY) |
http://www.thepsychologist.org.uk/archive/archive_home.cfm/volumeID_13-editionID_51-ArticleID_512-getfile_getPDF/thepsychologist%5Cdec00h2h.pdf
How should ADHD be treated?(CLICK ABOVE LINK FOR FULL ARTICLE)
Dr Steve Baldwin is Professor of Psychology and Director of the CACTUS Clinic at the University
of Teesside.
SADLY STEVE WAS KILLED ION THE SELBY RAIL CRASH 2006 ON THE WAY TO DELIVER A KEYNOTE AT A CONFERENCE ON ADHD.KEEP THE DEBATE GOING IN HIS MEMORY.
Dr Paul Cooper is at the School of Education, University of Cambridge. From 1 January 2001 he
will be Professor at the School of Education, University of Leicester.
HE HAS SINCE CHANGED HIS VIEWS CONSIDERABLY ON THE RISKS POSED BY PSYCHOTROPIC MEDICATION FOR CHILDREN.
He is joint author of the Society’s recent report Attention Deficit/Hyperactivity Disorder (AD/HD): Guidelines and
Principles for Successful Multi-agency Working (see p.630 to order your copy)
Given the complexity of the human
brain, and the relatively primitive state of
cognitive neuroscience as an empirical
discipline, this is not surprising.
Definitive conclusions about the
relationship between brain physiology,
higher cognitive functions and human
psychopathology are few and far between.
Inherited neurological differences, such as
those associated with ADHD, put their
possessors at greater risk than members of
the general population of developing certain
disorders. Whether the disorder develops
and the nature of its development depend
upon the complex interaction that takes
place within and between the molecular
level, the cellular level and the organism
in the external environment.
This interaction makes it entirely
disingenuous to frame a discussion around
the simplistic dichotomy of whether
‘ADHD is a biological brain dysfunction’
— this is inaccurate and misleading.
ADHD is best understood as
a biopsychosocial problem, and the ‘bio’
is in there because the research evidence
indicates that it is an important factor. The
research evidence does not tell us the
precise nature of the association between
neurology, cognition and behaviour in
ADHD, but it does point to some powerful
hypotheses. In this way ADHD is no
different from many other clinical
disorders. If psychologists were to demand
definitive evidence of causal relationships
between variables as a minimum standard
for accepting the validity of psychological
theories, then they would be left with a very
shallow pool of knowledge (if any at all).
A crucial issue here is the practical
value of psychological and other theory.
The theoretical underpinnings of the ADHD
diagnostic category provide professionals in
various fields with valuable insights that
inform their practice. Biochemical theories
have also given rise to non-pharmacological
treatments that are employed by some
physicians (Kinder, 1999). At a more
fundamental level, an informed
understanding of ADHD challenges the
deeply embedded, pernicious belief that
deviant behaviour in young people is always
either primarily volitional in nature or the
product of neglectful or deviant parenting.
Furthermore, the misrepresentation of
ADHD as a solely biological phenomenon
misses the point that a biopsychosocial
phenomenon, such as ADHD, requires
a multimodal treatment response requiring
multidisciplinary collaboration (British
Psychological Society, 2000). Medication
is largely regarded by informed and
competent clinicians as a sometimes
necessary but never sufficient intervention
for ADHD. Non-pharmacological
interventions include parent and family
interventions, behavioural, classroom,
pedagogical and social interventions, social
skills training, group and individual
psychotherapy (Teeter, 1998).
The use of medication The use of
medication in the treatment of ADHD,
particularly in children, has to be an issue
of concern to any thoughtful, socially
responsible person; not least because of the
scope for misuse of the drug for control
purposes. The ethical use of medication is
always for the benefit of the client. In the
case of methylphenidate the appropriate
dosage will have the effect of enabling the
individual to focus on tasks, thus
facilitating the learning of academic, social
and self-regulatory skills that are delivered
through other elements of the multimodal
approach. There is evidence to suggest that
its effectiveness in contributing to improved
social, behavioural and academic
performance is enhanced by the use
of additional non-pharmacological
interventions, and in some cases the dosage
level is reduced or the drug rendered
unnecessary by such non-pharmacological
interventions (Hinshaw et al., 1998).
With regard to the alleged absence of
a research base published in ‘international
refereed journals’ concerning the use of
medication, Greenhill (1998) provides
a comprehensive review of effectiveness
identifying 20 randomised clinical trials.
He concludes that there is ‘proven efficacy
of these compounds [i.e. psychostimulants]
during short-term controlled studies, as
shown by global ratings of ADHD
symptoms by teachers and parents’ (p.55).
It may certainly be the case that some
clinicians opt far too readily for medication
when deciding on treatment for ADHD.
The review conducted by Hinshaw et al.
(1998) of non-pharmacological approaches
would suggest that there are viable
alternatives to medication and that these
should be widely disseminated and be given
more attention by researchers from a range
of disciplines. However, the claims that
stimulant medication is the only
intervention used with ADHD, and that this
intervention has no ‘scientific’ credibility,
are frankly wrong.
dysfunction best treated with amphetamines.
Rather, hyperactivity disorders are
reversible, socially constructed conditions,
optimally treated with psychosocial
interventions and never with amphetamines
(Baldwin & Anderson, 2000).
December 2000
599
The Psychologist Vol 13 No 12
Head to head
PAUL COOPER
Ritalin and Equasym (two brands based on the
generic drug methylphenidate) are likely to be
made far more widely available after winning
approval from the National Institute of Clinical
Excellence (NICE), it was reported in
November.The guidance bans prescription to
children under the age of six and recommends
use only as part of a comprehensive treatment
programme; but NICE does conclude that the
drug is effective.Andrew Dillon, Chief Executive
of NICE, said the guidance was based ‘on a very
careful consideration of the evidence’. But
Janice Hill from the support group Overload
said that NICE ‘do not address any of the safety
concerns about Ritalin’.
CHRIS CHAPERON
What constitutes ‘scientific evidence’?
It is frankly unsurprising
that ‘short-term controlled studies’ of
methylphenidate show modifications in
a child’s behaviour. Amphetamines are
powerful drugs that act directly on the stilldeveloping
central nervous system of the
youngster. It is precisely these blunting
effects of MPH (i.e. narrowing of focus,
constriction of spontaneity) that are
favoured by some parents and teachers.
In real life, however, psychostimulants
are not used for the ‘short term’.
A recent audit survey has reported that
children aged 13 and 14 have been
prescribed psychostimulants continuously
for seven or eight years (Baldwin, in press).
Other children in the study were first
prescribed MPH at the age of three, four or
five, despite manufacturer guidelines not to
prescribe the drug to children younger than
six. Such flagrant disregard of clinical
guidelines is indefensible and unethical.
Minimum scientific standards should
always apply when determining what
would constitute an adequate dataset
published in international refereed journals.
Many of the 20 studies cited by Greenhill
(1998) were completed by non-independent
researchers funded by pharmaceutical
companies, then reported in journals
sponsored by drug companies. Results
from these studies can scarcely be
considered as valid, robust, independent
scientific research and should be
discounted when considering the supposed
‘evidence’ to support MPH prescription to
minors. Laurence Greenhill has received
research funds (or other financial
assistance) from at least six different drug
companies, including Richwood, Bristol-
Myers, Solvay,Wyeth-Ayerst, Glaxo-
Wellcome and Eli Lilly (Breggin, 2000).
Studies that reflect such obvious vested
Of course, the decision to prescribe
medication and other interventions should
always be based on data from the outcome
of a thorough multimodal assessment
procedure. A current example of good
practice in the UK includes the assessment
model described by Detweiler et al. (1999).
This is carried out by a multidisciplinary
team and involves clinical interviews, the
use of standardised, norm-referenced
behaviour-rating scales, a medical
examination, a computerised test of
vigilance and a cognitive ability test. The
use of neuroimaging technology in
assessment is uncommon. In time such
technology might form a valuable
component of assessment, but it would be
a mistake to believe that ADHD could ever
be diagnosed on the basis of a brain scan
alone.
The defining feature of a disorder such
as ADHD is the harmful effect of the
presenting symptoms on the individual’s
functioning at the personal and social level.
This means that the observational, personal
and historical data are always going to be
of central importance in assessing ADHD.
It must be stated that the assessment
techniques available for detecting ADHD
are far from perfect. Given the complexity
of the condition, this is hardly surprising.
However, the claims that ADHD is
sometimes diagnosed without adherence to
an appropriate assessment procedure (‘via
the internet or by telephone’) are alarming.
Such practice is thoroughly indefensible.
MPH and addiction The claim that MPH
is an addictive substance that is abused
must be treated with extreme caution.
It is true to say that, as an amphetamine,
it is one of a group of substances favoured
by drug abusers. As such, MPH should be,
and often is, treated as a substance that has
potential to be abused. Robin and Barkley
(1998) reviewed a number of US studies
carried out between 1980 and 1994. These
studies indicate that between 0.4 per cent
and 0.8 per cent of adolescents self-reported
using MPH for non-medical purposes, with
no significant increase in these figures over
time. This would indicate that the
overwhelming majority of youngsters being
prescribed MPH (approximately 3 per cent
of US school students) are not abusing it.
As for its addictive qualities, Stahl (2000)
reports that patients show little or no
evidence of tolerance, the need for
escalating doses, or withdrawal symptoms.
Finally ADHD is a controversial topic
that can give rise to passionate support on
the one side and vehement rejection on the
other. Neither of these positions is viable.
We cannot jump to the erroneous
conclusion that ADHD is caused by
biological factors alone, or that the
diagnosis is synonymous with the use
of medication, or that the fact that some
clinicians employ dubious assessment
methods means that all diagnoses of the
condition are bogus.
On the other hand, the extreme
evangelists for the condition make dogmatic
claims about the science underpinning the
condition. Their ideological position allows
them to accept the very lowest standards of
‘proof’ when they marshal evidence to
support their case. While they do this, the
ideologically opposed demand
unrealistically high standards of proof that
they would not require for topics that they
found more congenial.
In this case, we find the drug companies
vilified for their self-interest fuelled by the
profit motive, while the US federal
government becomes the arbiter of absolute
truth. I don’t have difficulty accepting the
possibility that commercial enterprises may
sometimes actively mislead the public in
order to make profits, or that governments
don’t always tell the truth. But I also
believe that if we are going to make
allegations of these kinds we have to
substantiate them with hard evidence.
More to the point, what are nonspecialists
meant to make of this fruitless
game of assertion and denial? I am
thinking of children with the diagnosis,
their parents and the front-line
professionals, such as teachers and social
workers, who work with them. They
deserve and need an honest account of
ADHD that separates evidence from
ideology and belief. Without such an
account how are they to make informed
decisions and choices about the position
they must take to make sense out of
a subject as complex as ADHD?
Head to head
The Psychologist Vol 13 No 12
The full range of psychosocial and educational interventions should be made available
I would stress that I agree
with the values and ideas
underlying Steve’s position.
We share a commitment to the view that
children with social, emotional and
behavioural difficulties should be helped.
Like him, I deplore the indiscriminate use
of psychostimulant medication in the
treatment of children with ADHD and
advocate evidence-based practice as
a guiding principle to the ‘treatment’ of
children with ADHD. Where we appear to
part company, however, is, as he suggests,
on the issue of evidence.
I agree entirely with the requirement for
good-quality scientific evidence published
in internationally respected journals.
However, I question the accuracy of the
claim that the studies reviewed by Greenhill
are published mainly in journals ‘sponsored
by drug companies’, with its implication
that the review should be dismissed as
unreliable. The journals drawn upon in this
review are: Archives of General Psychiatry,
Journal of Child Psychology and
Psychiatry, Journal of the American
Academy of Child and Adolescent
Psychiatry, Psychiatry Research, Journal
of Learning Disabilities, and
Psychopharmacology Bulletin. I think
readers would be surprised to see the
majority of these journals described in the
way Steve Baldwin describes them. If Steve
is making this claim then he needs to
provide evidence. Also, the strident
conclusion that these studies are fatally
interests can hardly be considered to be
scientifically independent.
It is irrefutable that drug companies
fund researchers to complete trials that
showcase their products favourably. The
so-called ‘drug approval process’ merely
requires that the minimum positive findings
are obtained and reported. In the process,
scores of trials with negative outcomes may
have been discarded and never reported in
science journals (Ruesch, 1992). There are
obvious linkages between pharmaceutical
companies and health policy makers both
in the UK (via the Department of Health)
and the USA (via the National Institutes
of Health).
In the USA congressional contributions
from drug companies in the first six months
of 1999 included Bristol-Myers (US$1.6m),
Glaxo-Wellcome (US$1.54m) and Eli-
Lilly (US$2.13m). Total drug company
contributions to congress between January
and June 1999 exceeded US$28.9m.
According to one medical observer:
…the ties between clinical researchers
and industry include not only grant
support, but also a host of other
financial arrangements. Researchers
serve as consultants to companies
whose products they are studying, join
advisory boards and speakers’ bureaus,
enter into patent and royalty
arrangements, agree to be the listed
authors of articles ghostwritten by
interested companies, promote drugs
and devices at company-sponsored
symposium, and allow themselves to
be plied with expensive gifts and trips
to luxurious settings. Many also have
equity in the companies… (Angell,
2000, p.517)
In 1998 the reported income for the first-
(Novartis), second- (Merck & Co) and
third-ranked (Glaxo-Wellcome)
pharmaceutical companies was US$10.6
bn, US$10.6 bn and US$10.5 bn
respectively (BW Health Wire, 1999).
Clinical psychologists in the USA will
likely be granted limited prescribing rights
in 2001. In the UK this debate about
prescribing has not yet been concluded.
The National Institutes of Health
Consensus Conference (NIH, 1998)
rejected the suggestion that MPH was
of proven benefit in social or educational
domains. The proposition that MPH will
assist school performance remains
unproven after more than 40 years of
psychostimulant prescription. Rather, MPH
is used for the social control of children
December 2000
601
The Psychologist Vol 13 No 12
Head to head
and teenagers.
In the UK the National
Institute of Clinical Excellence (NICE) has
confirmed that MPH should not be used
with children younger than six. However,
the NICE guidelines have not given
definitive prescription advice to clinicians
about children older than six.
What is the nature of ADHD? ADHD,
like other developmental disorders, can be
framed as a ‘biopsychosocial problem’.
Obviously, all disorders have some
biological component. The real clinical
challenge for psychologists, however, is
to provide effective psychosocial and
educational intervention alternatives that
work for children and their families.
Although a multimodal treatment response
is desirable, most children are prescribed
psychostimulants as a front-line, firstchoice
treatment by paediatricians and
psychiatrists (Baldwin, in press). Many
children prescribed psychostimulants in
the UK are simultaneously prescribed
sedatives, although this is specifically
contra-indicated owing to the risk of a drug
interaction. The complex nature of ADHD
means that the full range of psychosocial
and educational interventions should be
made available for children and teenagers.
What are the toxic properties of
methylphenidate? The proposition that
MPH is ‘safe, effective and not addictive’
requires much closer scientific scrutiny.
Results from low-level, quasi-scientific,
pharmaceutical industry-funded drug trials
are discordant with the actual experience of
clinicians working with children diagnosed
with ADHD. Adverse drug reactions
(ADRs) from MPH have been reported to
include (but are not limited to) confusion,
depression, zombie-like constriction of
affect, tachycardia, pituitary dysfunction,
blurred vision, dizziness, and evening crash
(Breggin, 1999).
Outcomes from an audit survey of
children referred to a university clinic
confirmed these ADRs, as well as a long
list of other symptoms, including agitation,
dyskenesias, tics, Tourette’s, nervous habits,
stereotypies, depression, amphetamine
look, stomach-ache, dry mouth, diarrhoea,
weight loss, growth suppression, chest pains,
psychosis with hallucinations, insomnia,
anorexia, vomiting, disturbed sexual function,
headache, and hypersensitivity (Baldwin, in
press). Every parent in this study of 80
families with children diagnosed with
ADHD reported they had not been told
about the addictive properties of MPH.
Moreover, none of them had been offered
treatment other than psychostimulants.
Some children had been prescribed
quantities of MPH that grossly exceeded
the recommended dosage levels. Many
children had been given MPH for seven
or eight years, against the manufacturer’s
recommendation for short-term use.
What is the value of ‘evidence-based
practice’? There is no dispute that the
debate about ADHD, psychostimulants and
alternative psychosocial and educational
treatments should be based on facts, not
ideology. The only real debate seems to
be about which information is considered
acceptable in the scientific community as
‘evidence’. Evidently there is agreement
about the need for ‘evidence-based
practice’, although disagreement about
what constitutes ‘evidence’.
flawed by the assertion that their authors
are funded by or otherwise associated with
a drug company, is more the sort of
inference that sensationalist journalists
rather than academics make. Furthermore,
the evidence for his own claim as to the
treatment practices of clinicians and the
experience of diagnosed individuals is
supported primarily by reference to a single
study of 80 families.
There is a contradictory element to
Steve’s account. On the one hand the evil
empire of the pharmaceutical industry is
ruthlessly and indiscriminately forcing
drugs down children’s throats. Yet by his
own admission there is evidence that, if
clinicians followed the drug companies
guidelines, at least one group of children
(i.e. those under six) would not actually
be prescribed medication. Also, the sideeffects
he claims are, by and large, reported
by the manufacturers, and can be
controlled through the adjustment of
dosage. If children continue to be
prescribed medication after they have
displayed seriously adverse reactions to
it that have not responded to changes in
dosage, then the prescribing physician is
responsible for this situation.
This brings me to another important
point of which Steve seems oblivious. The
relationship between clinical practice and
scientific research is not as straightforward
as Steve portrays it. Until the scientific
community comes up with cast-iron
research evidence capable of offering
definitive guidance to clinicians on every
eventuality that they are likely to
encounter, then clinical judgement will
continue to be an important clinical tool.
This means that ‘front-line’ professionals,
whom academic and research psychologists
work to support, are required to make
practical judgements often in the absence
of a definitive research-evidence base. Of
course, the available research should
inform clinical judgement. However, as the
current dialogue suggests, sometimes there
are conflicting ways of interpreting this
research. It is not responsible to exaggerate
or misrepresent either the flaws or the
merits of this research.
Steve rejects and maligns the research
and the researchers whose understanding
of ADHD conflicts with his own. In so
doing, he undermines his own case. In my
view there is a promising (though as yet
not definitive) body of neuroimaging and
genetic research pointing to the role of
biological factors in ADHD. As such,
ADHD offers a paradigm for researching
the relationship between biological,
psychological, sociological and cultural
factors.
The diagnosis is widely accepted by
clinicians throughout the world. More
importantly, perhaps, it is widely accepted
by a large portion of the potential clients
of these clinicians (including parents, adult
sufferers and the children themselves).
Many clinicians employ MPH in the
treatment of ADHD, though best clinical
practice is widely believed to require
a multimodal and, therefore,
multidisciplinary approach to treatment
(British Psychological Society, 2000).
There are examples of bad clinical practice,
poor research and unethical behaviour in
relation to ADHD (and everything else).
We will not further the interests of
individuals suffering directly or indirectly
from ADHD by basing our understanding
of ADHD solely on these negative cases.
There is clearly a great deal of progress
still to be made in developing effective
responses to ADHD. The complexity of the
problem is such that it is unlikely that any
single form of intervention will ever be
appropriate for all cases of ADHD. What
we now call ADHD will probably be called
something else in the fullness of time, and
the details of the diagnostic criteria and
subtypes will change. In the meantime we
need to acknowledge that ‘multimodal’
often equates with ‘multidisciplinary’.
Effective multidisciplinary working
involves disparate workers bringing their
distinctive expertise to a problem and
interacting in a mutually supportive and
co-operative manner. It would be foolish to
rule out the possibility of medical expertise
contributing something positive to such
a multimodal approach (sometimes in the
form of medication), just as it would be
foolish to see ADHD as a solely medical
problem.
December 2000
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This is the first of our ‘Head to head’ debates. If you have an idea for a topic that
would interest our readers and can suggest two people (psychologists, other
academics, practitioners or policy-makers) to take part, please e-mail your
suggestions to the Editor on jonsut@bps.org.uk.
References
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